Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection R 36 Month Inspection <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10146143 08/ 13/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Costco # 1039 Manteca <br /> Business Site Address City ZIP Code <br /> 2440 Daniel St . Manteca 195337 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Isaac Anderson 209 532 - 7320 Ext . <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CA 623541 /09 - 1749 8146912 1 06/ 12/20 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> VeederwRoot Level IV #1336878 Ex 10/22/20 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used : R Manufacturer Guidelines (Specify) Remove Tank gauge , bring fuel float to 90 % <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.) T1 87A T2 87B T3 91 T4 Additive <br /> What is the tank inside diameter? (Inches) 120 120 120 48 <br /> Is the fill piping secondarily contained? R Yes ❑ No R Yes ❑ No R Yes ❑ No R Yes ❑ No <br /> Is the vent piping secondarily contained ? R Yes ❑ No R Yes ❑ No R Yes ❑ No R Yes ❑ No <br /> Veeder- Root Veeder- Root Veeder- Root Veeder- Root <br /> Overfill Prevention Equipment Manufacturer(s ) <br /> What is the overfill prevention equipment ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> response when activated ? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) R AN Alarm R AN Alarm R AN Alarm R AN Alarm <br /> Are flow restrictors installed on vent piping? R Yes ❑ No R Yes ❑ No R Yes ❑ No R Yes ❑ No <br /> At what level in the tank is the overfill prevention 101 101 101 39 <br /> set to activate? (Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which 90 90 90 90 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating R Yes R Yes R Yes R Yes <br /> condition to respond when the substance ❑ No ❑ No ❑ No ❑ No <br /> reaches the appropriate level? (Specify in section V . ) L(Specify in section V . ) (Specify in section V. ) (Specify in section V. ) <br /> IV . SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results R Pass ❑ Fail R Pass ❑ Fail R Pass ❑ Fail R Pass ❑ Fail <br /> j V . COMMENTS <br /> All items marked "Fail' must be explained in this section. Any additional comments may also be provided here. <br /> i <br /> i <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations , title 23, division 3 , <br /> chapter 16, section 2637.2 and all the information c tained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more component an this form accommodates, additional copies of this page maybe attached. <br /> CFR. = Califnmin FnvirnnmPnfnl RPnnrflnn .vefam . in = Idenfifirafinn. I IST = I Indammunrl cfnranP tank. ICC = Infemnfinnnl CnffP Cnunril. AN = At idihIp and visual <br /> k <br />