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W.O.# NW1-2338727 Cust Ref# : COCO-0015297489 UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page i of i) Type of Action ❑installation Inspection ❑Repair Inspection 36 Month Inspector I. FACILITY INFORMATION CERS ID 101Date of Civer)3A PrIntentbn Equipment Inspection Bussn"s Name(Same as Facility Name or DBA-Doing Business As) t'irZ � 10 Business Site Add(�s City ZIP Code 7LA00 rJ r•/1 (., �)-v, - - c / S 3 il. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Techn n Perfortining the Inspection(Print as shown on the ICC Centihcation.) Phone q Contractor/Tank Tester Llodnse P ICC Certification# ICC Certifliclition Expirat n Date Overfill Prevention Equipment Inspection Training and Certcations(List applicable certifications.) 00 !� - C, r III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFOAMAtION Inspection MethodManufacturer Guidelines(Specify) Used ❑Industry Code or Engineering Standard(Specify): ❑Engineered Method(Specify): Attach the inspection procedures and all documentation required to determine the results. u of Attached Pages TANK 10:(By tank number,stored product,etc.) f.M i r�gq3 1 k CS f ' What is the tank inside diameter?(inches) Is the rill piping secondarily contained? Yes ❑No %Yes ❑No O.Yes ❑No ❑Yes ❑No Is the vent piping secondarily contained? ❑Yes ®-No ❑Yes W}No ❑Yes D§.No ❑Yes ❑No Overfill Prevention Equipment Manufadurer(s) 4tr r k0el G tit/ &PW What is the overfill prevention equipment response ❑Shuts OH Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts OH Flow when activated? (Check all that apply.) ja Restrict Flow aResMets Flow aRestncts Flow ❑Restricts Flow Alarm PAN Amann Alarm ❑ArV Alarm Are flow restikyors installed on vent piping? I 9,Y—es ❑No $Lyes ❑No AYes ❑No ❑Yes ❑No At what level in the tank is the overfill prevention set / to activate?(Inches from bottom of tank.) I D 5 i o5 I OS What Is the percent capacity of the tank at which the a n U � overfill prevention equipment activates? f i 5 /c' g 5 - Is the overfill prevention In proper operating conditiony� Yes Yes ❑Yes to respond when the substance reaches the appropriate levell No(Specify in V.) ❑No(Specify in V.) Cj No(Specify in V.) ❑No(Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfifl Prevention Inspection Results ❑Pass Fait ❑Pass Fad 1 ❑Pass OFa,l [I Pass ❑Fail V. COMMENTS Any items marked-Fail- ust be explained In this section. Any additional comments may also be provided here. lct�75 care- CJ! 6�_f g6CIC, i h r 5�1ck�ld t° 90/ VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was Inspected in accordance with California Code of Regulations,Title 23, Division 3,Chapter 16,Sectlon 2637.2 and all the information contained herein Is accurate. UST Service Tect]! Sign e 1 If the facility hes more compo ants than thils form accommodates,addldonst copies of this page may be aaachad. CERS=Caf(anie Enwonnenilal Reporting System.ID=Identilication.LIST=Undekgokrd SiOnVe Tarte,ICC=lrlanational Code Card.NV=Audile and V" OVERFILL INSPECTION REPORT