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W . O . # NW1 - 2337835 Cust Ref# : COCO - 0015297489 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (page f of 1) <br /> Type of Action D Installation Inspection ❑ Repair Inspection <br /> 36 Month Inspection <br /> t <br /> CERS ID j Z (" I. FACILITY INFORMATION <br /> \ () \ V ''1 r <br /> Data 1of rO11v p Prevention Equipment Inspection <br /> Bustness Name (Same as Facility Name or DBA-Daing Business As) ` U <br /> C h.-U 47 -off 1 G ) <br /> Business Sita Address City ZIP Coda <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> orming the Inspasitnn (Print as shown an the ICC Certification.) P a # <br /> Name of U T Service Technlcia Performing /�/ / <br /> Contractor i Tank Test r License #' ICC Certification # ICC Certificationiretlon Date <br /> kA <br /> Overfill Prevention Equipment inspection Training and Certifications (Ust applicable comitcetlars l <br /> YN\ ' r z1 <br /> � e\ � c° 02f 1 0 ' 1 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method 1$1Nanufacturer Guidelines (Spectfy): <br /> Used: \\ <br /> D Industry Code or Engineering Standard (Specify): <br /> D Engineered Method (Specify): <br /> Attach the inspection procedures and all documentation required to determine theresults. # of Attached Pages <br /> TANK ID: (By tank number, stored product, etc.) <br /> What is the tank inside diameter? (Inches) ' <br /> Is the fill piping secondarily contained? ® VasNa ❑ Yes ENo ❑ Yes D No D Yes D No <br /> Is the vent piping secondarily contained? D Yes ffNo ❑ Y" No I1 Yes D No Yes 0 No <br /> Overfill Prevention Equipment Manufacturer(s) <br /> rl4) <br /> What Is the overfill prevention equipment response Shuts Off Flow Shuts Off Flow ❑ Shuts Oft Flow <br /> when activated? ❑ Shuts Off Flow <br /> (Check all that apply,) D Restricts Flow D Restricts flow D Restricts Flow D Reshicfs Flow <br /> D AN Alarm D AN Alarm D AN Alar D AN Alarm <br /> Are flow restdotors installed an vent piping? ❑ Yas ❑ No ❑ Yes No ❑ Yes <br /> D No [� Yes ❑ No <br /> At what level In the tank is the overfill p aventiat sat <br /> to activale? (Inches from bottom of tank.) ` o fly ei J ,, t T j <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating condition ( Yes O Yes D Yes I D yes <br /> to respond when the substance reaches the <br /> appmriate level? 1 D No (Specityin V) D No (Specify in V) D No (Specify in V) D No (Specify in V.) <br /> IV. SUMMARY OF INSPEC'T'ION RESULTS <br /> Overfill Prevention Inspection ResultsLi Pass ❑ Fall Pass ❑ Fall (� Pass ❑ Fati ❑ Pass ❑ Fail <br /> V: COMMENTS <br /> Any hems marked lFall' must be explained in this section. Any additional comments may also be provided here. <br /> VI, CERTIFICATION BY LIST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipmentwas inspected In accordance with California Code of Regulations, Title 230 <br /> Division 3, Chapter 16, Section 2637.2 and all the Information contained herein is accurate. <br /> UST Service Technician Signature <br /> Afol <br /> . <br /> ff the facility has more companants than thli form accommodates, additional coplos of this page may be ettached. <br /> CERS _ E Reporting System ID bartilcatiM UST = Sor�agaTernK,C= Owe Castn6AN and VistW, <br /> 14IfT <br /> CA overfill form <br />