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UNDEROROUND. STORAGE TANK . <br /> . ' <br /> OVERFILL PREVENTION EQUIPMENT INBPECTION R6pORTJ'ORM (Page 1 of 1 ) <br /> Type ofAGlon <br /> Inslallailon Inspection ❑ Repair Inspection 0 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> Date of Overflli Pro entlon Equipment Inspection � <br /> CERS ID <br /> Business Namo (Same as FBCIIIIyNamo orOeA-Ooleg f3uslnessAs.) <br /> 'P f City ZIP Code ' <br /> 9uslness Slte Address <br /> NDEROROUND STORAGE TANK SERVICE TE NNICIAN INFORMATION <br /> Phone i! <br /> Name of UST Se Ica Techniden Padorming the Inepecllon (Prinf as shmvn an the ICC Cedl!lcalfonJ EM <br /> J " LGY'C ICC Cedlgcallon 6 ICC Cedliicallon Expiration Dale i <br /> Conlracto an ester Llcenso 11 <br /> Overfill Prevenllon Equipment Inspection Training and Codlfleallons (Usl eppHoable cetihcallons.) <br /> III.!! OVERFILU PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> inspection Method Used: XManufacturer Guldeilnea (Specht) ' <br /> p Industry Code or Engineering Standard (Speclry) <br /> p Engineered Method Speolly <br /> Affach ilia Inspection procedures and all documentation required to determine the rosutle, i! of Alleched Pages: <br /> Tank ;D: (6yienknumbet, steredpmducb atop) \)16•zi.- V? � ( , <br /> What is the tank Inside diameter? (Inches) <br /> le the 611 piping secondarily contained? Yes 0 No ea 0 No Yes ' 0 No 0 Yas (� No <br /> is the vent piping secondarily contained? 'Yes 13 No Yea ❑ No Yes ❑ No 0 yes Ll No <br /> t"YAVIk \ „n <br /> OvedlilPrevention Equipment ManuNclarsr(s) rQAN),;AIamo <br /> Shule Off Flow �huta Off flow ff Flow Shuts OtfFlowWhat is the overfill prevention squipmenl ❑ Restricts Flow ❑ Rasldcls Flay ts Flow p Resldcls Flaw <br /> response when activated? AA/ Alarm <br /> (Chock all thatapplA.) [JAA1Alarm [ IAA/ Alarm ❑Yes No p Yes No op Yas jJ NPAre flow restridors Installed on vent ptpfng9 At what level in the tank Is the overfii( preventlon , 2S <br /> set (a activists? (Inches from bottomo/tank.) ( 0012.5 j <br /> Whet la the percent capacity of the tank at which yQfo°ea ( <br /> the overfill prevention equipment activates? \ Yes ❑ Yas ' <br /> Is the overfill prevention in proper operating Yes /OYes ' <br /> condition to respond when the substance ❑ No ❑ No ❑ No CI No <br /> (Specify In <br /> reaches the appropriate Ievei? (Specify In secllon V.) (Specify In section V.j aeclion V.) <br /> n V:) Opacity In sectioi <br /> • . , :. IV.; SUMMARY OF:INSPECT.ION RESULTS6;' ;:':.' <br /> p <br /> Pat Pass CI Fall ,, Pass ❑ Fall 0 Pass ❑ Fah <br /> Pass <br /> Ovedlil Prevention Inspection Results . . t <br /> . ; . :N,1.''t;COMMENTSi .i :n':.: ,;a)::• .:., 1' ;. <br /> •All Items marked 'Fall'musfbeexplalnedInhits seallon. Anyaddltknslaommartfsmayalsob mvtdedhere. <br /> LP <br /> r <br /> :VI,;;:CERTIFICATION6 ,.U8T. SERVICE$TECHNICI{jN 'CONRUCTINO,r 88)NPP CT(QN .• , ' <i{ <br /> •I hereby curtly that the overilll prevention equipment was hrspocted In accordance with Catlfomla code of Regulatlone, title 23, division 3, <br /> Information conlalned herein is accurate, <br /> chapter 16, section 2837,2 a all the /7 <br /> UST Service Technician SIA u e <br /> Alfthefaclillylmsmore compevents hall' (Ill ormaccommodefes, addtllonalcopiesof tills pagemaybeaflaehed. <br /> in -. in„�ne.�m., Here ummmrrumrlcLv-arw look ICCalnlnmallnnai Corte Cmmcil. ANaAUdlbls andvlsrlal <br />