Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Pagel of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10180881 10/ 16/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> BLACK HAWK PETROLEUM <br /> Business Site Address City ZIP Code <br /> 5611 E WATERLOO RD STOCKTON CA 95215 <br /> lit UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> David Winkler (209 ) 744 - 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08- 1739 Ex . 3/31 /2020 8883059- UT 1 /29/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11 - 16- 18 OPW 104-633 Ex 3- 14-21 ' ; <br /> Emco #3207 Ex . 09-21 -2020 VR : B34975 ATG : 2/8/20 " , t.;, <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : REMOVED DROP TUBES 4 2019 <br /> Used : <br /> ❑ Industry Code or Engineering Standard (Specify) : ENVIRONME <br /> ❑ Engineered Method (Specify): 'AP TM <br /> ENT H <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 <br /> TANK ID : (By tank number, stored product, etc.) 87 91 DSL <br /> What is the tank inside diameter? (Inches) 96 96 96 <br /> Is the fill piping secondarily contained? ❑ Yes I] No ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes R No ❑ Yes 0 No ❑ Yes 0 No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW <br /> 61SO 61SO 61SO <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> ❑ <br /> (Check all that apply.) Restricts Flow El Restricts Flow El Restricts Flow El Restricts Flow <br /> ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes R No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 85 86 86 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 93 94 94 <br /> Is the overfill prevention in proper operating condition ❑x Yes rEjNo <br /> ❑x Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level ? ❑ No (Specify in V.) (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results 9 Pass ❑ Fail ❑x Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations , Title 23 , <br /> Division 3 , Chapter 16 , Section 2637 . 2 and all the information contained herein is accurate. <br /> UST Service Technician Signature V <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, A/V = Audible and Visual <br />