Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Inspection ❑Repair Inspection X 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10180561 12-18-2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> ESCALON MINI MART <br /> Business Site Address City ZIP Code <br /> 1097 E YOSEMITE � ESCALON 95320 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> David Winkler (209) 744-0112 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 Ex.3/31/2020 8883059-UT 1/29/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW , Phil-Tite &EVR Phase 1 1009853708 Ex 11/29/20 OPW 104-633 Ex 3-14-2020 <br /> Emco #3207 Ex. 11/16/20 ATG: VR: B34975 ATG:2/8/20 INCON 1009853708 Ex.11/30/2020 _ <br /> 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): REMOVED OPW DROP TUBES <br /> Used: <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages 3 <br /> TANK ID:(By tank number,stored product,etc.) 87 91 <br /> What is the tank inside diameter?(inches) 111 111 <br /> Is the fill piping secondarily contained? ❑Yes Fm]No ❑Yes 0 No ❑Yes ❑No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? ❑Yes ❑x No ❑Yes 0 No ❑Yes ❑No ❑Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW <br /> 61SO 61SO <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow 0 Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> ❑AtV Alarm ❑A/V Alarm ❑A/V Alarm ❑AIV Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ❑x No ❑Yes E No ❑Yes ❑No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set 101 103.5 <br /> to activate?(Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95 97 <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑Yes El Yes El Yes <br /> to respond when the substance reaches the <br /> appropriate level? El No(Specify in V.) ZNo(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results Z Pass ElFail ❑ Pass ZFail ❑ Pa ' Mail r-T15ass- ail <br /> V. COMMENTS a <br /> Any items marked"Fail"must be explained in this section. Any additional comments may also be provided here. <br /> 91 FAILED FLAPER AT 97% i� a 9 ZO2 <br /> ENVIRONMENTAL HEAL. H <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INsPEOPI®ITIMENT <br /> I 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 the information contained herein is accurate. <br /> UST Service Technician Signature V � <br /> if the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AN=Audible and Visual <br />