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r(CN PEURP1200-17 <br /> APPENDIX C-5 <br /> LIST OVERRLL EQUIPMENT INSPECTION <br /> AUTOMATIC SHUTOFF DEVICE AND BALL FLOAT <br /> Facility Name: Owner: <br /> Address: Address: <br /> City,State,Zip Code: City,State,Zip Code: <br /> Facility I.D.#: Phone#: <br /> Testing Company: I Phone#: Date: <br /> This data sheet is for inspecting automatic shutoff devices and ball float valves.See PEVRP1200 Section 7 for inspection procedures. <br /> Product Grade <br /> Tank Number <br /> Tank Volume,gallons <br /> Tank Diameter,inches <br /> Overfill Prevention Device Brand <br /> Type ❑Automatic ❑Automatic ❑Automatic ❑Automatic ❑Automatic ❑Automatic <br /> Shutoff Device Shutoff Device Shutoff Device Shutoff Device Shutoff Device Shutoff Device <br /> []Ball Float ❑Ball Float ❑Ball Float ❑Ball Float ❑Ball Float ❑Ball Float <br /> Valve Valve Valve Valve Valve Valve <br /> AUTOMATIC SHUTOFF DEVICE INSPECTION <br /> 1.Droptube removed from tank? ❑Yes ❑No ❑Yes 0 N ❑Yes 0 N El Yes El No []Yes ❑No El Yes El No <br /> 2.Drop tube and float mecha- ❑Yes ❑No ❑Yes ❑No ❑Yes []No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> nisms free of debris? <br /> 3.Float moves freely without <br /> binding and poppet moves into []Yes ❑No ❑Yes []No ❑Yes ❑No []Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> flow path? <br /> 4.Bypass valve in the drop tube ❑Yes ❑No ❑Yes []No ❑Yes ❑No ❑Yes []No ❑Yes ❑No ❑Yes ❑No <br /> open and free of blockage(if ❑Not Present ❑Not Present ❑Not Present ❑Not Present ❑Not Present ❑Not Present <br /> present)? <br /> 5.Flapper adjusted to shut off ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No []Yes ❑No ❑Yes ❑No <br /> flow at 95%capacity?* <br /> A"No"to any item in Lines 1-5 indicates a test failure. <br /> BALL FLOAT VALVE INSPECTION** <br /> 1.Tanl<top fittings vapor-tight El Yes 0 N ❑Yes 11 No El Yes El No [I Yes E)No ❑Yes ❑No El Yes 11 No <br /> and leak-free? <br /> 2.Ball float cage free of debris? ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> 3.Ball free of holes and cracks ❑Yes ❑No ❑Yes []No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> and moves freely in cage? <br /> 4.Vent hole in pipe open and ❑yes []No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> near top of tank? <br /> 5.13all float pipe proper <br /> length to restrict flow at 90% ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> capacity?*** <br /> A"No"to any item in Lines 1-5 indicates a test failure. <br /> Test Results ❑Pass ❑Fall ❑Pass EI Fail ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass []Fail <br /> Comments: <br /> *Use manufacturer's suggested procedure for determining if automatic shutoff device will shut off flow at 95%capacity. <br /> **If a ball float is found to fail the inspection,another method of overfill must be used. <br /> ***Use manufacturer's suggested procedure for determining if flow restriction device will restrict flow at 90%capacity. <br /> Tester's Name(print) Tester's Signature <br /> 0 pei.org <br />