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0DERGM)UN D.S_TDRAGE.TANK <br />OV REF ILL PREVENTION EQUIPMENT INSPECTION REPORT FORM Wage I of <br />11 <br />iwi f� ❑ nal"ondm aecjiml ❑ Reoalr Inanection 36 Month <br />Ins_aectlon <br />EAWLIIY-INFORMATION <br />- <br />---- -- - -`—Drll�, <br />�k',�I17 - <br />c,lS�v�filLPi uvunli4t4€4��ul�ts.tiLu <br />Susin�sllama/f.S�aa F�ri1�' ; :ante, or OAq l2oitzQ�cr.Sint�9s. Ash <br />C� DLVJDYI <br />, <br />UNDERGROUND STORAC;F. <br />TANK SERVIU.IECHNIOIAN-INEORMADON <br />4 N1ULe.utlJ$LSflYIuTe4i 1 1 ca, _ <br />0 tho lir r <br />t �t'litic Orr �yc Z <br />� <br />-oI1Z <br />CsntsatitarTat� Tc�tet�4a�t� e# Y.'/' �etSrR�.�, <br />QYerfid Preveniion Egui meet Inst on Tr int <br />_ _g--n� and Cettificalhns �l rst vpplicahtr _friicannn> <br />to b bti <br />OVERFILL PREVENTION <br />EQUIPMENT INSPECTION INFORMATION <br />rn�u,9il r� <br />I�r,ldflnUrev.pnrr G1Ikt"liges 1.4necilvl <br />�I lc�; ... <br />- _ - - <br />❑Jadushv Cade or Engineering standard A <br />acirVt <br />O _Eupineerord Method f Suyst(K� <br />�A4ttachthelnat:Bcltntt <br />nrocedur andaltttycuatsn4ttlgu tettulced f"eteuldhe Caro -UL&., ut yiia_I, v F ty <br />Ad atimher stored <br />L, <br />Whet is the tank Inalde dlameter9 tin .heal <br />I I <br />LCJIflt)[0410 ariiv ctmleit�o�l? <br />1.. o No <br />o ti',o; ❑ mo <br />❑ 1'us. ❑ Id. <br />la the vent olgtng aecondarlfv cent_Yned') <br />—_� <br />YA Euw <br />D xu DAQ <br />D YRA DAA <br />�Iclve <br />TIoG� <br />- <br />Shnta ON Flew14 <br />Shuts OB Flgw <br />❑Shu off Flow <br />fl Shuts Ofl Flow <br />1t1(tletf8.the gYBlflil OreV9nilaR eglllpmeRt <br />eta. Ql <br />❑.UUW9 F.lo# <br />(],(U@tl�i:IF EIs11Y <br />❑�G61[1Gt&EINA <br />teapougo when activate I? <br />!_7 eltf -�EL1� <br />❑ANAlartn <br />❑.EQCBtatm <br />❑AIYAIuuq <br />❑AIYHlctun <br />D yma D.GIg <br />o I" U=wj <br />Are sow rechlarerc i:s ad n,t vent gl , r <br />uxki Qzam <br />IQ ❑mtl9 <br />�t Yd��tleStel�IL the tatilcisthe av nfitl_uc.evenuon <br />To <br />7 b <br />set to activate. � llnCites /rom ltn8otn_gt tank I <br />I IMIdti3beuercentwwgaUo(2"aketydilch <br />QG <br />I J (�/o <br />�Sa�U <br />tha overfill otgventlnn e"meu"Gliyajaj2 <br />Is -the oyoiffigroyentlon In proper operating moxm <br />�� ❑ $ <br />❑ <br />Goudition to r.9pgnd when the rnhetanve ❑ <br />❑� <br />r-7 �r„ <br />r•flctlEs�lte a oroptleteltYel? Serifv In ueclfon V.1 <br />(S eclfv In serifou Y,1 <br />u3oerl in serllori V_) <br />velLllPrs1rs11UgtL1tt5pectiulLResu la - Q s:a 019 <br />X PAU ofes ❑Peres ==D t ail <br />p54 0 FAO <br />MMENTS <br />All items marked 'Fait' must be erolained In lhta aerrtal. Any adgkio lg(comntenta <br />may also he JWAL <br />. <br />CERTIFICATION RY UST SERVICE TECHNICIAN <br />CONDUCTING THIS INSP€G'fiON <br />I harobv certify that ih Yfllflil f3Y�llttQll_wu_himggi�dlil�fccordance 1Hjl��r�illfQ��� itoguldtiap <br />- -- <br />13 26 -Az a t' call <br />2 <br />It Ute MOW <br />has am muonents than this <br />lotm accommodatesa additional <br />coYlas <br />of this <br />oaue may he aaachod. <br />SEP 282018 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />