Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Pagel of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection 0 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181409 6/6/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> ARMY COURT BUILDING <br /> Business Site Address T� STOCKTON <br /> ity ZIP Code <br /> 1624 ARMY COURT 95206 <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 /> David Winkler 1 ( 209 ) 744- 0112 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08- 1739 Ex . 3/31 /2020 8883059- UT 1 /29/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- EBW , PhikTite & EVR Phase 1 1009853708 Ex 11 /29/20 OPW 104-633 Ex 3- 14-2020 <br /> Emco #3207 Ex . 11 / 16/20 ATG : VR : B34975 ATG : 2/8/20 INCON 1009853708 Ex . 11 /30/2020 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : REMOVED OPW DROP TUBE <br /> Used : <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 3 <br /> TANK ID : (Bytanknumber, stored product, etc.) DSL <br /> What is the tank inside diameter? (Inches) 95 <br /> Is the fill piping secondarily contained ? 7EE11 <br /> es R No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> i. Is the vent piping secondarily contained? es ❑x No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW <br /> 61SO <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> (Check all that apply.) :EE:1 Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ❑ A/V Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 783/4 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 88 . 5 <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑ Yes ❑ Yes ❑ Yes <br /> to respond when the substance reaches the <br /> Elappropriate level ? No (Specify in V.) ElNo (Specify in V.) ElNo (Specify in V.) ElNo (Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ❑ Fail ElPass ElFail ❑ Pass E] Fail IEEI Pass E] Fail <br /> V. COMMENTS <br /> Any items marked "Fail" must be explained in this section. Any additional comments may al <br /> .JUN 2 0 2019 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with G g la i s , t e 23 , <br /> Division 3 , Chapter 16 , Section 2637. 2 and all the information contained herein is accurate . DEPART [OFNT <br /> UST Service Technician Signature ^ I <br /> If the facility has more components thanthis 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 />