Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page i of 1 ) <br /> Type ofAction ❑ installation Inspection ❑ Repair Inspection 1] 36 Month inspection <br /> 1 . FACILITY INFORMATION <br /> CER51D Date of Overfill Prevention Equipment Inspection <br /> 10180733 10/3012019 <br /> Business Name (Same as Facility Name or DBA•Doing Business As) <br /> Arco 7147 <br /> Business Site Address City ZIP Code <br /> 120$ E March Lane Stockton 95210 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the JCC Certification.) Phone # <br /> Elodlo Sanchez 1 ( 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 Cert# 100695 Exp . 10/24/2020 <br /> 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Dx Manufacturer Guidelines (Specify): <br /> Used : Tank 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 T1 91 T2 DSL T3 <br /> What is the tank inside diameter? (inches) 9O 5 9005 90 . 5 <br /> Is the fill piping secondarily contained? ❑ Yes 93No ❑ Yes I] No ❑ Yes M No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes (] No ❑ Yes ❑x No ❑ Yes M No ❑ Yes El No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW <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.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow El Restricts Flow <br /> ❑ AN Alarm ❑ AN Alarm D AN Alarm D AN Alarm <br /> Are flow restrictors installed on vent piping? ❑ Yes 19 No © Yes [E No D Yes 0 No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (inches from bottom of tank.) 78 78 . 5 78 <br /> What Is the percent capacity of the tank at which the 91 91 . 4 91 <br /> overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating condition ❑x Yes [9 Yes 0 Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> 1V. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results Pass D Fail []x Pass ❑ Fail 19 Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any Items marked "Fait" must be explained in this section. Any additional comments may also be provided here. <br /> RECEIVED <br /> irv <br /> Vi . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipm was Inspected in accordance with California o9de q fA!p jtcpe T1e 231 <br /> Division 3, Chapter 16, Section 26 2 and all th forma n contained herein is acc I`J i t <br /> UST Service Technician Signature F) F Pia . 1 NIF IT <br /> 146" <br /> E If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Caffornia Environmental Repo6V System. iD = identification, UST = Underground Storage Tank, ICC = lin emational Code Counct AN = Audile and Visual <br />