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UNDER GROUND.STORAGE TANK. . <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action Installation Inspection ❑Repair Inspection <br /> ❑36 Month Inspection <br /> I.FACILITY INFORMATION <br /> Dale of overfill Prevention Equipment Inspection <br /> CERS ID —� <br /> r <br /> Business Name(Same as FacilityAlame or DBA Doing Business As.) <br /> P I City ZIP Code <br /> Business Site Address Cl 4�3&10 <br /> r. <br /> Il. NDERGROUND STORAGE TANK SERVICE TE HNICIAN INFORMATION <br /> ' Phone{{ <br /> Name of UST Se Ice Technician Performing the Inspection(Print as shown on the 1CC Certification,) Ext <br /> LLy�. C ICC Codification{) ICC Certificallon Expiration Date <br /> Contracto[H-ank Tester License t! <br /> Overfill Prevention Equipment Inspection Training and codifications(List applicable certtUcatlons.) <br /> IIL: <br /> OVERFILL,PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> lnspectIon Method Used: Manufacturer Guidelines(Specify) <br /> D Industry Code or Engineering Standard(Specify) <br /> ❑Engineered Methodi <br /> Attach the Inspection procedures and all documrequired to determine the results. {)of Attached Pages: <br /> Tank ID:(By tank number,stored product,etc.) s El. �� <br /> What Is the lank Inside diameter?(inches) <br /> Is the fill piping secondarily contained? Yes D No es ❑NoYes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? VYes D No Yes C1 No `Yes ❑No ❑Yes 11 No <br /> VYCX V, <br /> Overfill Prevention Equipment Manufacturer(s) <br /> huts Off Flow 'Shuts Off Flow ❑Shuts OH Flow ❑Shuts Off Flow <br /> What Is the overfill prevention equipment <br /> ❑Restricts Flow [I Restricts Flow [I Restricts Flow El Restricts Flow <br /> response when activated? <br /> (Check all that apply.) D AN IV Alarm D AAlarm ❑AAI Alarm El AN Alarm <br /> Are flow restrictors Installed on vent piping? ❑Yes No ❑Yes No yes <br /> 0 0 Yes N4 <br /> 09 1 <br /> At what level In the tank is the overfill prevention (;�C ;2 tj <br /> set to activate?(Inches from bottom of tank.) f(��) Z Y <br /> What Is the percent capacity of the tank al which `��"�'�/ �Gj Ck �1K <br /> the overfill prevention equipment activates? ` <br /> Yes Pi^Yes Yes 0 Yes <br /> Is the overfill prevention In proper operating No <br /> condition to respond when the substance 0 No ❑No D N0 US act in section V. <br /> reaches the appropriate level? (Specify In section V:) (Specify In section V.) (Specify 1n section V.j (Specify ) <br /> :1V. - <br /> :,SUMMARY INSPECTION RESULTS";. <br /> Overfill Prevention Inspection Results E3Pass 0 Fall ❑Pass ❑Fail 0 Pass D Fall T 0 Pass ElFall <br /> V. =COMMENTS. <br /> Ad/tams marked'Fall'must be explained in this section. Any additional cornments may also b Lprovided here. <br /> i l - <br /> L. .CERTIF1CgTlON BY U5T.SERVICET IN <br /> ECHNICIAN:CONDUCTING;THIS. $PECTIQN <br /> I hereby certify that the overfill prevention equipment was Inspected in accordance with californla Code of Regulations,title 23,division 3, <br /> chapter 96,section 2637.2 and all the Information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has moe components than tills form accommodates,addltlonal copios of this page may be attached. <br /> MCI <br /> icr-InlematlanalCode Council.AIV=Audible and visual <br />