Laserfiche WebLink
19242436 . 2 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation inspection 21 Repair Inspection ❑ 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181235 10/ 15/2019 <br /> Business Name (Same as Facility Name or DBA•Do/ng Business As) <br /> Arco 5450 <br /> Business Site Address City ZIP Code <br /> 1617 W Fremont Stockton 95203 <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 /> Bodo Sanchez ( 925 ) 551 -7555 <br /> Contractor ! Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 220793 8887127 6/4/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> OPW Tech Ceti# 100695 Exp . 10/2412020 <br /> 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method 2) Manufacturer Guidelines (Specify):UseTank Chart, OPW, Tape Measure <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 <br /> TANK ID : (By tank number, stored product, etc.) 87 T2 91 T3 <br /> What is the tank inside diameter? (inches) 92 92 <br /> Is the fill piping secondarily contained? ❑ Yes ❑ No R1 Yes ❑ No 2 Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes ❑ No ❑ Yes QQ No ❑ Yes [] No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow 0 Shuts Off Flow (] Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) Restricts Flow ❑ Restricts Flow ❑ Restricts Flaw ❑ Restricts Flow <br /> ❑ AiV Alarm ❑ AIV Alarm ❑ AAl Alarm ❑ AIV Alarm <br /> Are flow resirictors installed on vent piping? ❑ Yes ❑ No © Yes [9 No ❑ Yes No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set 78 5/8 78 3/4 <br /> i <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? 91 . 5 91 . 6 <br /> Is the overfill prevention in proper operating condition ❑ Yes [9 Yes [M Yes ❑ Yes <br /> to respond when the substance reaches the <br /> j appropriate level? E] No (Specify In V.) [INo {Specify in V.) ❑ No (Specify in V.) E] No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑ Pass El Fall IE Pass [3 Fail M Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS rw% raffm e% 11 <br /> Any items marked °Fail" mdst be explained In this section. Any additional comments may also r e he <br /> OCT ; 1 2019 <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTIN07HKAWOMNHEALT <br /> I hereby certify that the overfill prevention equipmentwas pected in accordance with California Pa §A@at "f s , Title 23, <br /> Division 3 , Chapter 16, Section 2637.2 an I the info on con ined 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 = CWomia Environmental Reporting System, ID = Identification, UST = UndeMmund Storage Tank, ICC = International Code Council, NV = Audible and Visual <br />