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FEB 0 2019 UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page t of 1 ) FTypeof Action Installation Inspection ❑ Repair inspection ❑ 36 Month inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection Ekisiness Name (Same as Facility Name or DBA-Doing Business As) Business She Address City 1 - 21P Code 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the inspection (Print as shown on the iCC Certification.) Phone # Contractor l Tank Tester License # ICC Certification # ICC Certi tion iration Date . ' Overfill Prevention Equipment Inspection Training and; ',��ons (Lis applicable certiRcations.) III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION inspection Methocl Manufacturer 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 Attached Pages TANK ID: (By tank number, stored product, etc.) What is the tank inside diameter? (Inches) Is the fill piping secondarily contained? [ Yes ❑ No Yes ❑ No IX Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? Yes ❑ No to Yes ❑ No ( Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) What is the overfill prevention equipment response Shuts Off Flow Shuts Off Flow [A Shuts Off Flow ❑ Shuts Off Flow when activated? (Check all that apply) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ A/V Alarm ❑ AA/ Alarm ❑ AIV Alarm ❑ A/V Alarm Are flow restrictors installed on vent piping? ❑ Yes $0 No ❑ Yes &'No ❑ Yes Qi No ❑ Yes ❑ No At what level in the tank Is the overfill prevention set to activate? (Inches from bottom ortank.) What is the percent capacity of the tank at which the overfill prevention equipment activates? ® 3 ® Olt Is the overfill prevention in proper operating condition Yes ayes (�tj Yes ❑ Y =ffify to respond when the substance reaches the appropriate level? E1No (Specify In V.) ❑ No (Specify in V.) ❑ No (Specify In V.) ❑ N IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results 10 Pass ❑ Fail Pass ❑ Fail Pass ❑ Fail ❑ 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 Code of Regulations , Title 23, Division 3, Chapter 16, Section 2637.2 and all the information contained herein is accurate. UST SerlirA.Techniclan Signature 3, Ki If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = Ca6fomia Ervirvnmental Repor" System, ID = identification, UST = Underground Storage Tank, ICG = International Code Coundi, AN = Audble and Visual