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W.O.# NW1-2337824 Cust Ref#: COCO SO-0015267473 UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page t of 1) Type of Action ❑Installation Inspection ❑Repair Inspection Month Inspection I. FACILITY INFORMATION CERS ID 1 U rt / > Date of Overfill Prevenlion Equipment Inspection Business Name(Same as F cility Name or DBA-Dong Business As) !� Ght,Vmn - j ,^ r, ! Business Site Address CityZIP Code r 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# Edw;n p' acts. goo-666-a�� Contractor I Tank Tester License# ICC Certification# IC Certification Expiration Date Y31 0 05A �- -17 Prevention Equipment Inspection Training and Certifications(List applicable certlRcstlons.) Fra n K1: f;_t),-III I Coo i c. � W 1 ►b 111; OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method VlAanufacturer Guidelines(Specify) Used: i ❑Industry Code or Engineering Standard(Specify): ❑Engineered Method(Specify): Attach the Inspection procedures and off documentation required to determine the results. #of Attached Pages TANK ID:(By tank number,stored product•etc.) f 'A, -3 eara f What is the tank inside diameter?(Inches) n _/G13 •' Is the fill piping secondarily contained? rp-Yes ❑No Mes ❑No Yes ❑No ❑Yes ❑No Is the vent piping secondarily contained? ❑Yes IB40 ❑Yes pkb ❑Yes M40 ❑Yes ❑No Overfill Prevention Equipment Manufacturer(s) Klin Qlkj. /;n i n What Is the overfill prevention equipment response tjj-6huts Off Flow is Off Flow Ca-Shuts Ort Flow ❑Shuts Off Flow when activated? (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑AN Alarm ❑AN Alarm ❑AtV Alarm ❑AIV Alarm Are Now restrictors installed on vent piping? ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No At what level in the tank Is the overfill prevention set —, to activate?(inches from bottom of tank.) (�•j C� What is the percent capacity of the tank at which the overfill prevention equipment activates? Is the overfill prevention In proper operating condition Ayes ®Yes ❑Yes to respond when the substance reaches the to level? ❑No ISpecily in V.) ❑No(Specifl in V.) ❑No(Specify In V.) ❑No(Specify in V.l IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ss ❑Fad I §4ass ❑Fad ass ❑Fed ❑Pass ❑Fail V. COMMENTS Any items marked"Fail'must be explained in this section. Any additional comments may also be provided here. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION 1 hereby certify that the overfill prevention equipment was Inspected in accordance with California Coda of Regulations,Tine 23, Division 3,Chapter 16,Section 2637.2 and all the information contained herein Is accurate. UST Service Technician S n#ture /.1 if dw facility has more components than effis form accommodates,additional copies of this papa may be attached CERS=Caillim a EtrMorcrnrral Raporag Syslam.ID-kferMification.UST=tlndeig xind Storage Tann ICC=krarrresual Code Coaxal,AN= , 32018 OVERFILL INSPECTION REPORT =NVIRONMENIAL HEALTH DEPARTMENT