COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10180633 3/5/2019 Business Name (Same as Facility Name or DBA-Doing Business As) SHORTSTOP Business Site Address City ZIP Code 20A WEST TURNER RD LODI 95240 I1 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # David Winkler (209 ) 744- 0112 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 08- 1739 Ex . 3/31 /2020 8883059- UT 1 /29/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , PhikTite & EVR Phase 1 1009853708 Ex 11 /29/20 OPW 104-633 Ex 3 - 14-2020 Emco #3207 Ex . 11 / 16/20 ATG : VR : B34975 ATG : 2/8/20 INCON 1009853708 Ex . 11 /30/2020 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) : Used : REMOVED DROP TUBES ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 5 TANK ID : (By tank number, stored product, etc.) 87 91 DSL What is the tank inside diameter? (Inches) 128 128 128 Is the fill piping secondarily contained? ❑ Yes R No ❑ Yes E No ❑ Yes ❑x No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes EI No ❑ Yes [] No Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW 61 SO 61 SO 61 SO What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow 0 Shuts Off Flow ❑ Shuts Off Flow when activated ? (Check all that apply) El Restricts Flow El Restricts Flow El Restricts Flow El Restricts Flow ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping ? ❑ Yes N No ❑ Yes [E No ❑ Yes 0 No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 109 113 113 1 /2 What is the percent capacity of the tank at which the overfill prevention equipment activates? 90 . 8 93 . 6 93 . 8 Is the overfill prevention in proper operating condition X Yes 0 Yes Z Yes ❑ Yes to respond when the substance reaches the appropriate level ? ❑ No (Specify in V) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results 0 Pass ❑ Fail 0 Pass ❑ Fail Q Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section . Any additional comments maRI V E D SEP VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION 1 O '��,H Title 23 , I hereby certify that the overfill prevention equipmentwas inspected in accordance 'ul2 �a® � �� 'f �4d Division 3 , Chapter 16, Section 2637 . 2 and all the information contained herein is accurate.[) ER1A1RTMFNT- UST Service Technician Signature V W If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Usual