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W.O.# N W 1-2338727 Cust Ref# : COCO-0015297489 UNDL;tGROUND STORAGE LANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM cagN Type of Action ❑Inswatdn Inspection []Repair Inspecoo! 36 M[atth InspectK• I. FACILITY INFORMATION CERS IDI r Dated e*tion Equhpmyri Inspection Busi s Name(Same as Factlity Name or DRA4)"Business As) --� C � i t,• 2_ I Z kA 10 Buwwss Site Address city ZIP rode z: I,� if. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Pedonnov she I'Ispectron("int as shown on the ICC Cemncatton! T phone a �t'k��'I' l , •r e•,!r Wt,- 'C�� JC�.. � Contractor I Tank Tester License Of I ICG C"ficabor,a ICC tion+E at Date LOvr r L Preventm Equipment Inspection Tr �� n Z Training and Cartrfa.tttons(Wt appacebla cerndicanons) I � i tLL, Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Medved Manufacturer Guidelines(Speavyi - -- . I Used ❑Industry Gorle or Engmeennq Stan3ard(Specify) ❑Engineered Method(Sciecife) ---- Attach the Inspection procedures and all documentation required to determine the rowlts. •of Artacned Pages TANK ID:(By tank numoer storedpvoouct•etc) i rpt i w/h r 1. z; f Wha!,s the tank inside oamNer,(Inches) Is Me NI piping secondardy contained Yes ❑No oX-]es. ❑No Yes ❑No ❑Yes ❑No Is the vent piping seconded)contained? ❑Yes Mho ❑Yes &E�No ❑Yes OLNo ❑Yes ❑No Overfill Prevenbor Eanomeri Manutactunmsh -Ct r etc Wha!is ttw overu prevention eq,rpment response ❑Shy as OR Flow ❑Shuts Glt Flow ❑Stwb OR Flow ❑Shuts OR Flow Whet,eaivated? �Er (Chock all that apply) 14Re�trcts Flow ty Restricts Flow JaRestnds Flow ❑Restricts Flow V.&(1•Alarm Awrn MAN Alarm ❑AN Aann Are lbw restifdurs installed on vend pppmg7 s ❑No KLYes ❑No Yes ❑No ❑Yes ❑No At what level m the tank is the overfill prevention set to o aclivsle^()riches hom bottom of tank I ' L9 5 'O—�; What is the percent capacity d the tank at which the f, ci overbtl prevention eatmpment activates f i s ,�__ ,S �C Is the ovaArl prevention in proper operating Condition ye, as ❑yes Ip respond When the substance reaches the a o e lever idol f Speedy in V) ❑No(Spec,),to V, ❑No(Speedy in V) ❑No(Sosafy m v) IV. SUMMARY OF INSPECTION RESULTS Ov l Prevw*un Inspection Results _ _ ---_ ❑Pass Fad 10 Pass EyFait I [:]Pan Feil I ❑Pass ❑Fad V. COMMENTS Any items marked*Fail' sf be pleated in this secbnn Any additional comments may also be provided here la- � Ci : C' cell G: f Cl Str/i'f �h� :.)L c �t� r! <jc !C I VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONOUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was Inspected in accordance with California Code of Regulations.TUN 23, Division 3,Chapter 16,Section 2637.2 and all the IMornution contained herein is accurate. UST Service(ITechnician Sig r M the&CMry hAYTneril,eompodents Nan Ihis form aeeommodrtas.addWonat copies of this page may be attached. CERS•C MWu Errwnrmartal Repi"V System.D=Idae43am UST=Underground Swage Tart.ICC=Ysxnebrg Cad RI N/ men D OVERFILL INSPECTION REPORT I^AY h 7'119 ENVIRONMENTAL HEALTH DEPARTMENT