COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action El Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 9/24/2018 Business Name (Same as Facility Name or DBA -Doing Business As) Quik Stop # 121 Business Site Address Cily ZIP Code 1196 W . Louise Ave Manteca 95336 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Juan Jauregui ( 916 ) 889 - 3897 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 5246964 8/30/2019 OverfilWrevention Equipment Inspection Training and Certifications (List applicable certifications.) Phase 1 EVR - Cert # 100580 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify): Used : ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) Gasoline - 87 Gasoline - 91 What is the tank inside diameter? (Inches) 893/4 893/4 Is the fill piping secondarily contained ? ❑x Yes ❑ No E] Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑x Yes ❑ No ❑>< Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturers) oPW oPw What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated ? x Restricts Flow x Restricts Flow (Check all That apply.) ❑ ❑ El Restricts Flow El Restricts Flow ❑ AIV Alarm ❑ AfV Alarm ❑ AN Alarm ❑ AfV Alarm Are flow restrictors installed on vent piping? U Yes ® No U Yes ® No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 801 /2 80 1 /2 What is the percent capacity of the tank at which the overfill prevention equipment activates ? 95 % 95 % Is the overfill prevention in proper operating condition ❑ Yes ❑ Yes ❑ Yes ❑ Yes to respond when the substance reaches the appropriate level ? _ ❑x No (Specify in V.) ❑x No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results _ ❑x Pass ElFail Q Pass El Fail ❑ Pass El Fall ❑ Pass ❑ Fall V. COMMENTS Any items marked "Fail" must be explained in this section . Any additional comments may also be provided here. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations , Title 23, Division 3 , Chapter 16, Section 2Y7. 2 and all the information contained herein is accurate . UST Service PnS ala !f the lacility hvents th n his for accommodates, additional copies of this page maybe attached. CERS = Californiaeporting t i, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AIV = Audible and Visual i