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PEURP1200-17 LIST OVERFILL EQUIPMENT INSPECTION AUTOMATIC SHUTOFF DEVICE AND BALL FLOAT Facility Name: Owner: Address: Address: City, State, Zip Code: City, State, Zip Code: Facility I.D. #: Phone #: Testing Company: Phone #: Date: This data sheet is for inspecting automatic shutoff devices and ball float valves. See PEI/RP1200 Section 7 for inspection procedures. Product Grade Tank Number Tank Volume, gallons Tank Diameter, inches Overfill Prevention Device Brand Type ❑ Automatic ❑ Automatic ❑ Automatic ❑ Automatic ❑ Automatic ❑ Automatic Shutoff Device Shutoff Device Shutoff Device Shutoff Device Shutoff Device Shutoff Device ❑ Ball Float ❑ Ball Float ❑ Ball Float ❑ Ball Float ❑ Ball Float ❑ Ball Float Valve Valve Valve Valve Valve Valve AUTOMATIC SHUTOFF DEVICE INSPECTION 1. Drop tube removed from tank? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 2.Drop tube and float mecha- []Yes ❑ No []Yes ❑ No []Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No nisms free of debris? 3. Float moves freely without binding and poppet moves into ❑ Yes ❑ No ❑ Yes ❑ No []Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No flow path? 4.Bypass valve in the drop tube ❑ yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No open and free of blockage (if ❑ Not Present ❑ Not Present ❑ Not Present ❑ Not Present ❑ Not Present ❑ Not Present present)? 5.Flapper adjusted to shut off ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes D No [--]Yes ❑ No ❑ Yes ❑ No flow at 95% capacity?* A "No" to any item in Lines 1-5 indicates a test failure. BALL FLOAT VALVE INSPECTION** 1.Tank top fittings vapor- tight ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No and leak -free? 2. Ball float cage free of debris? ❑ Yes ❑ No ❑ Yes ❑ No []Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 3.13all free of holes and cracks ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No and moves freely in cage? 4.Vent hole in pipe open and ❑ Yes ❑ No []Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No near top of tank? 5.Ball float pipe proper length to restrict flow at 90% ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No capacity?*** A "No" to any item in Lines 1-5 indicates a test failure. Test Results ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail Comments: * Use manufacturer's suggested procedure for determining if automatic shutoff device will shut off flow at 95% capacity. ** If a ball float is found to fail the inspection, another method of overfill must be used. *** Use manufacturer's suggested procedure for determining if flow restriction device will restrict flow at 90% capacity. Tester's Name (print) Tester's Signature 0 pei.org