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qw <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM{Page I On) <br /> Type of AG'mn ❑Installation lnspeclion O Repair inspection p36Mornhlnspention <br /> _ I. FACILITY INFORMATION <br /> CER51a Date of avemll Preveneon Equi 11 <br /> 10160567 p^�^inspection <br /> 8/23/1 S <br /> Business Name(Same es Faclfdy Name arDBA-Ddng BusinBss Asf <br /> EMILS LIQUOR <br /> eusirress Slte Address Cdy 21P Cade <br /> 1405 CALIFORNIA ST ESCALON 95320 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name Of UST service Tecnmdan Parfonnirg lint Inspection(Pdntasahown-MOlcc cedtvicevon.) phone n <br /> Edward Steams 209 744-0112 <br /> Contractor I Tank Tesler License K ICG cernfloation 1t ICC Cerl'a�oolian-toffaeon Dale <br /> 14-1760 Ex.09/30/2020 8883080-UT 11/9/2020 <br /> Overfill Prevention Equipment Inspection Training and Cedidcatlons(List appseaa b wniaeapnnq) <br /> FF-EI PhIkTli 8 EVR Phase 1 1009893708 EX 11/29/2020 OPW 104-635 Ex 3-14-2020 <br /> Emco 3205 Ex.11116/2020 A7G:VR A31048 EX.8/9l19 Incon 1009893708 11/30/2020 <br /> Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Melhed ElMitrab urer Cwldellnes(Sp"): <br /> used REMOVE AND INSPECT OPW <br /> 0 Industry code or Enginaenng Standard(Spenlj�): <br /> 0 Engineered minew(Spec fy): <br /> Attach the inspection procedures and al!documentatfe n"ulmd to dorennfne the results. a otAgaUed Pages 2 <br /> TANK 10:(By tank number.staredpmduer,etc.) DIESEL <br /> What a the tank imide domete?(Inches) 128 <br /> Is the Net piping seeoMarity contained? 0 Yes ©No Oyes ON. 0 Yes 0 No AYeSO Is the van[pipingsewrrdentywnleinetl? 0Yes Da No- OYes ❑N- 0Yes ONO OveFll Prewnaon EquipmeM ela,exNoner(s) om <br /> What is the overhg prevention equipment eaionee Ox SMRS On Flow OSh_0nFf_ Dshuts ONFluw wilenactivated? 0 Restricts Flow D Resinols Flpw O Restricts Flow(chockwrthatapply.) O fWAO. EAV No- DPN Alarm Ave flow nntri insgd on vent piping? 0 Yes M No O Yes 0 Na 0 Yes 0 No <br /> At-al level in the tank is One-fill pm,nitl.sal 115 <br /> to adiyate?(orches frpm bottom o/tank.) <br /> what is the percent oapadty of tie tankat which the 94.8 <br /> overfill prownGCn equipment adivates? <br /> Is the ov of prevention in proper operating wrdition (Dyes 0Yes Dyes ❑Yes <br /> W respond wfien the substance reaches the <br /> apptopnate level? 0 No(SpeGfyN V,) ❑No(SpacRy in v.) El No(SpecAy In V.) ❑No(Speeiy In V) <br /> IV, SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Reauns Q Pala 0 Fail 10 Pass 0 Fall 1 0 Pass 0 it 0 Pass O-11 <br /> V. COMMENTS <br /> Any items marked-Fail-must be explained ie this secow.Any additional sD mrs may also be pmvlded here. <br /> N. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING iHlS INSPECTION <br /> LI reby certify that the overfill pmventlon eqWineentwas I.spec din accordance with Califomia Code ofRegulations,Title 23, <br /> aion 3,Chapter 16,Section 2637.2 and ag the information-lined ins in Is---urate.Service Tecn-4-Signature �(aclllryhes mom pomppnenisloan.,a term accommedaMs,edNnonel copies oepageY .—had. <br /> s Ug(prtti Em4gvrvlbl RepSF99/sWn,l�=pmM tint UST=LYtlei9ruwrr151oagsTaklCC^IN+eEma CakCaml.AN,NtlNeatllkral <br /> a� <br /> �D <br /> 7 �� <br />