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W.O.# NW1-2338727 Cust Ref# : COCO-0015297489 UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page 1 of f) Type of Action ❑Installation Inspection ❑Repair Inspection 36 Month Inspection I. FACILITY INFORMATION CERS ID O Date of v (erpll Pr4vention Equipment Inspection Busi2eiE Name(Same as Facility Name or DBA-Doing Business As) ( r 10 Business Site Add "� r� City ZIP Code 3 140 r.1, l /`'q �t� �1vF - !n 19S3 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Techrljpan Perfo ing the Inspection(Print as shown on the ICC CeRrrication_) Phone k Contractor I Tank Tester Ucdnse tI ICC Certification# ICC ton Expi bate 0 Overfill Prevention Equipment Inspection Training and Certifications(Uat applicable ceMfrcationa.) 00 1 - 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFOWAtION Inspection Method 2Manufacturer Guidelines(Specify) Used: ❑Industry Code or Engineering Standard(Specify): ❑Engineered Method(Specify): Attach the Inspection procedures and all documentation required to determine the results. s of Attached Pages TANK ID:(By tank number,stored product,etc.) P_M i c 1 i C S What is the tank inside diameter?(inches) Is the fill piping secondarily contained? tlYes ❑No V)Yes ❑No O.Yes ❑No ❑Yes ❑No Is the vent piping secondarily contained? ❑Yes ®-No ❑Yes I344o ❑Yes KNo ❑Yes ❑No Overfill Prevention Equipment Manufacturer(s) Cl cG lit/ W What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow (h kall activated?apply) 14 Restricts Flow ((Restricts Flow aRestricts Flow ❑Restricts Flow V3AN Alarm R-AN Alarm Hann ❑AN Alarm Are flow restrictors installed on vent piping? s ❑No Dyes ❑No XLYes ❑No ❑Yes ❑No Al what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) O 'I C)505 What is the percent capacity of the tank at which the overfill prevention equipment activates? Ujc' S C/ 9S d� Is the overfill prevention in proper operating condition es Yes e�( ;; ❑Yes to respond when the substance reaches tthe appropriate level? No(Specify in V.) ❑No(Spec/fy in V) No in V.) ❑No(Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑Pass Fail 10 Pass E2rFa,I 1 ❑Pass Fed ❑Pass ❑Fail V. COMMENTS Any items marked'Fall"must be explained in this section. Any additional comments may also be provided here. e'll F lcc�7s cLiz czl f q s`lc.f i fwY �i ��d tx qa 1. 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,Section 2637.2 and all the information contained herein Is accurate. UST Service Technician Signq4e N the feciffty ha mor.compo ants than this form accommoans,adiffdanat coplas of this page may be attached. CERS=Calbrnie EnWanna1al R P"V 9ysbrrti iD=Ider6cabon.UST=Underpouhd Sbrage Tank ICC=Irismaeonal Code Cored.AN=Auditie and Visual