Laserfiche WebLink
©ven° tr l➢ 1P frevenflon ffm9pection e _ ries Deviees <br /> Date: — — ED <br /> : i <br /> Owner: Ppb 014 <br /> Oci fah 4 F. (119 <br /> Facility : S� + L % Iq <br /> O Model umber: rl2t4v1kjyvi Ari kQNMENTALHEALTH <br /> DEPARTMENT <br /> Pant a )PICC efe Height SeuRug CaicallllOwn <br /> Tank I Tank 2 Tan C$ 3 Tanis 4 <br /> Maximum Tank volume Per: A, Gallons <br /> Max shut off requirement for flapper is 95 % B 95 % <br /> Multiply Max tank volume by 95 % c Gallons <br /> Use tank chart or ATG to determine height of n Inches <br /> calculated volume /06 Ui>> <br /> Measure top of fill riser threads, or face seal E Inches Gy (� <br /> adapter (l� <br /> Tank diameter (From Tank Chart) F Inches qMee <br /> Upper Tube in Tank (G) F-D = G G Inches D , <br /> Subtract 2" from upper tube in tank G-2 "= K K Inches <br /> Calculated minimum upper tube length (I) I Inches , <br /> K+E=I <br /> Actual measured upper tube length (Without J Inches5 <br /> fill adapter) ( <br /> Pant 2 e device Cerilifficati®n Oriterin Evaljaunflon <br /> Does the overfill prevention device meet the 95 % <br /> requirement? <br /> Is the actual measured upper tube length 6. 5 inches or <br /> more than the fill riser? (J must be 6 .5 " or more than E) <br /> Does the overfill prevention device function as required? <br /> (Inspect the device for damage, contamination , freedom of i <br /> movement, weakening due to wear and corrosion) <br /> Device Overfill Certification PASS / FAIL '? .S <br /> Drop Tube Testing PASS / FAEL <br /> Technician certifies that the device is operationally compliant. <br /> Signature of Technician :. c Date : <br /> c <br /> Technician 's Name : \,j v 1� Aa 0 4ds4 <br />