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_3 2019 UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page t if 1) up Type of Action LOInstallation Inspection ❑Repair Inspection Q 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection l—3-19 stress Name(Same as Facility Name or DBA-Do(ng Business As) Business Site Address City _ ZIP Code II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspectlon(Print as shown on the ICC Certification.) Phone# :z 6 k2Nt% i IM;;-4N-W1 2S Contractor I Tank Tester License# ICC Certification# ICC Certi i alion ENpiratibn Date .` OvenNI Prevention Equipment Inspection Training and Ce ' catons(Li applicable cerfifrcations.) III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection MethodManufacturer Guidelines(Specify): Used: ❑Industry Code or Engineering Standard(Specify): ❑Engineered Method(Specify): Attach the Inspection procedures and all documentation required to determine the results. #of Anached Pages TANK ID:(By tank number, stored product,etc.) What is the tank inside diameter?(Inches) Is the fill piping secondarily contained? ( Yes ❑No 19 Yes ❑No II Yes ❑No ❑Yes 0 No Is the vent piping secondarily contained? %Yes ❑No fA Yes ❑No f%Yes ❑No ❑Yes ❑No Overfitl Prevention Equipment Manufacturer(s) What is the overfill prevention equipment response EA Shuts Off Flow f.0 Shuts Off Flow Shuts Off Flow ❑Shuts Off riow when activated? (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑AN Alarm ❑AN Alarm ❑AN Alarm ❑AN Alarm Are flow restnctors installed on vent piping? ❑Yes g No ❑Yes &yNo ❑Yes IZ No ❑Yes ❑No At what level In the tank Is the overfli prevention set to activate?(inches from bottom of tank.) Zrj V; to "LG What is the percent capacity of the lank at which the Q overfill prevention equipment activates? *4 4 063 Is the overilN prevention in proper operating conditionpl Yes X Yes QLYes ❑Yes to respond when the substance reaches the 91 appropriate level? 1 ❑No(Specify in V.) ❑No[Specify In V.) ❑No(Specify in V) ❑No(Spacify in V.) IV. SUMMARY OF INSPECTION RESULTS overfill Prevention inspection Results 10 Pass ❑Fail Pass ❑Fail 1 10 Pass [j Fail ❑Pass ❑Fall 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 I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations,Title 23, Division 3,Chapter 16,Section 2637.2 and all the Information contained herein is accurate. UST SerlimlechnIcian S' nature f y the facility has more components than this form accommodates,addlfionai copies of this page may be attached. CERS-Casomia Environmental Reporting System,10=lderdi o4on,UST-Urdemmund Skrage Tank,ICC=i0tematiord Coda Couri Ant-Audbe and Visual