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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action E]Installation Inspection ❑Repair Inspection ❑36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Business Site Address oD n./ Mf�-( .q �� City ZIP Code <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performipg the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Contractor I Tank Tester License# ICC Certification,# ICC Certification Expiration Date <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method [(Manufacturer Guidelines(Specify): <br /> Used: <br /> ❑Industry Code or Engineering Standard(Specify): ENVIRONMENTAL 0EALTr <br /> ❑Engineered Method(Specify): nFPARIMENT <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages <br /> TANK ID:(By tank number,stored product,etc.) <br /> What is the tank inside diameter? (Inches) <br /> Is the fill piping secondarily contained? ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) 1 / vf`) C'1-7/ <br /> What is the overfill prevention equipment response E]-Shuts Off Flow ❑'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 /> ❑AN Alarm ❑AN Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ❑No ❑Yes ❑No ❑Yes Q No ❑Yes ❑ No <br /> At what level in the tank is the overfill prevention set <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? <br /> Is the overfill prevention in proper operating condition ❑Yes ❑Yes 0 Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑Pass ❑Fail Q Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked"Fail"must be explained in this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <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 ° <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 />