COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page -I of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection 9 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10182295 9/28/2018 Business Name (Same as Facility Name or DBA-Doing Business As) ORLANDO ' S MARKET Business Site Address City ZIP Code 18754 E . HIGHWAY 26 LINDEN 95236 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Zane Nimmo (209 ) 744 - 0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 04- 1676 Ex . 03/31 /2019 8883064 -UT 6/ 1 /2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , PhikTite & EVR Phase 1 10009843708 Ex 11 -29-20 OPW 104-632 Ex 3- 14-2020 Emco 3206 Ex , 11 /14/2020 ATG : VR : A28446 Ex. 9/28/19 Incon # 1009843708 Ex. 11 -30-20 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method 0 Manufacturer Guidelines (Specify) : Used : VEEDER ROOT TLS 0 Industry Code or Engineering Standard (Specify) : BALL FLOATS ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 2 TANK ID : (Bytanknumber, storedproduct, etc.) 1 - DIESEL 2 - 87 OCT 3 - 91 OCT What is the tank inside diameter? (Inches) 127 . 50 127 . 50 127 . 50 Is the fill piping secondarily contained ? ❑ Yes 0 No ❑ Yes 0 No ❑ Yes 0 No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes 0 No ❑ Yes 0 No ❑ Yes 0 No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) VEEDER ROOT V R V R What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated ? ❑ (Check all that apply.) Restricts Flow ❑ Restricts Flow El Restricts Flow El Restricts Flow 0 A/V Alarm A/V Alarm 0 A/V Alarm ❑ A/V Alarm Are flow restrictors installed on vent piping ? x❑ Yes ❑ No 0 Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 108 . 5 108 . 5 108 . 5 What is the percent capacity of the tank at which the overfill prevention equipment activates? 90 . 0 % 90 . 0 % 90 . 0 % Is the overfill prevention in proper operating condition 0 Yes 0 Yes 0 Yes ❑ Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V) ❑ No (Specify in V) ❑ No (Specify in V.) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results 0 Pass ❑ Fail 0 Pass ❑ Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section . Any additional comments may also be provided here . ALL BALL FLOATS VERIFIED AND OPERATIONAL . VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipmentwas 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 Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Usual