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w <br /> a� <br /> RECEIVED <br /> 241- <br /> "UNDERGROUND.STORAGE TANK' <br /> -OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM TL <br /> Type of Action: ❑Installation Inspection ❑Repair Inspection 36 Month In I MENT <br /> VII.FACILITY INFORMATION <br /> CERS ID: Date of Inspection: <br /> 10181559 8/2/2018 <br /> Business Name(Same as Facility Name or DBA): <br /> Kaiser Foundation - Manteca <br /> Business Site Address: City: Zip: <br /> 1777 W Yosemite Ave Manteca 95337 <br /> VISI.UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> i <br /> Name of UST Service Technician(Print as shown on ICC Certification): Phone: <br /> Jeff Badders (949) 306-1890 <br /> Contractorfrank Tester License#: ICC Certification Number: <br /> 808313 15252456 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List all applicable certifications): <br /> Veeder-Root A20392 <br /> 1X"U40RGR0IINC STORAGE'TANK SERVIC"E TECHNICIAN INFORMATION" <br /> Test Method Used ❑ Manufacturer Guidelines(Specify): <br /> 0 Industry Code or Engineering Standard(Specify):PEI RP 1200 <br /> ❑Engineered Method(Specify): <br /> Number Of Attached Pages: <br /> Attach the inspection procedures and all documentation required to determine the results. <br /> Tank ID (by tank number, product, etc.) T2 Diesel <br /> Tank diameter(Inches): 92" <br /> Is fill piping secondarily contained? ❑Yes 0 No ❑Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No <br /> Is vent piping secondarily contained? ❑Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No <br /> Overfill Prevention Equipment OPW <br /> Manufacturer(s): PSL <br /> What is the overfill prevention ❑ Shuts off Flow ❑Shuts off Flow ❑Shuts off Flow F] Shuts off Flow <br /> equipment response when activated? ❑ Restricts Flow ❑Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply) ❑AN Alarm ❑AN Alarm ❑AN Alarm ❑ANAlarm <br /> Are flow restrictors installed on vent piping? ❑Yes 9 No ❑Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No <br /> At what level In tank will overflow prevention 8(„ <br /> activate In Inches from tank bottom 7 <br /> at s the percent capacity of tank at which <br /> 93% <br /> overflow prevention activates? <br /> Is the overfill prevention in proper ❑■ Yes ❑Yes ❑Yes ❑Yes <br /> operating condition to respond when <br /> substance reaches the appropriate ❑No* ❑No* ❑No* ❑ No* <br /> level? *(Specify in section V) *(Specify in section V) *(Specify in section V) *(Specify in section V) <br /> X.SUMM.ARY.OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results 0 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> XI.COMMENTS <br /> All items marked"Fail'must be explained in this section.Any additional comments may also be provided here: <br /> XII.CERTIFICATION BY UST SERVICE TEOHNICIAN CONDUCTING THIS INSPECTION . <br /> 1 hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations,title 23, <br /> division 3,chapter 16,section 2637.2 and all information contained herein is true and accurate. <br /> UST Service Technician Signature <br /> Revision Date:4/11/2018 <br />