Laserfiche WebLink
C <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection El 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181525 4/5/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> CITY OF STOCKTON CORP YARD <br /> Business Site Address City ZIP Code <br /> 146 S . LINCOLN ST ISTOCKTON 95206 <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 /> Edward Stearns (209 ) 744-0112 <br /> Contractor / Tank Tester License # ICC Certification # C Certification Expiration Date <br /> 14 - 1760 Ex . 09/30/2020 8883080- UIC <br /> T 11 /9/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- EBW , PhikTite & EVR Phase 1 1009893708 Ex 11 /29/2020 OPW 104-635 Ex 3- 14-2020 <br /> Emco 3205 Ex . 11 / 16/2020 ATG : VR A31048 Ex . 8/9/ 19 Incon 1009893708 11 /30/2020 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : <br /> Used : REMOVE AND INSPECT OPW <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 3 <br /> TANK ID : (By tank number, stored product, etc.) 87 DIESEL <br /> What is the tank inside diameter? (Inches) 90 90 <br /> Is the fill piping secondarily contained ? ❑ Yes ❑x No ❑ Yes Z No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes E] No ❑ Yes Z No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) oPw OPW <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow 0 Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) Restricts Flow 171 Restricts Flow El Restricts Flow El Restricts Flow <br /> ❑ A/V Alarm ❑ A/V Alarm ❑ AfV Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent piping ? x❑ Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 76 80 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90 93 . 6 <br /> Is the overfill prevention in proper operating condition ❑x Yes Z Yes ❑ Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ❑ Fail Z Pass ❑ Fail ❑ 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 <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 = International Code Council, AN = Audible and Visual <br />