COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSU<NN REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection i pection ® 36 Month Inspection L FAC IkMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181329 . ,L4`L 3- 10- 19 Business Name (Same as Facility Name or DBA-D ' m s As.)Q�� MANTECA CHEVRON Business Site Address ity ZIP Code 1257 W. YOSEMITE � ��` MANTECA CA II . UNDERGROUND STORAR~nRVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection ( sho on the ICC Certification.) Phone # MARK WILLIAMS 559 688 - 2977 Ext, Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date A304137 8198890 9-27- 19 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) OPW . PHIL TITE III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used : ❑ Manufacturer Guidelines (Specify) ® Industry Code or Engineering Standard (specify) .PEI 1200 ❑ Engineered Method (Specify) Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages : Tank ID: (By tank number, stored product, etc.) 91 87 DIESEL What is the tank inside diameter? (Inches) 92 92 92 Is the fill piping secondarily contained? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No OPW OPW OPW Overfill Prevention Equipment Manufacturer(s) What is the overfill prevention equipment ® Shuts Off Flow ® Shuts Off Flow ® Shuts Off Flow ❑ Shuts Off Flow response when activated? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow (Check all that apply.) ❑ AA/ Alarm ❑ AA1 Alarm ❑ AAl Alarm ❑ AN Alarm Are flow restrictors installed on vent piping? ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No At what level in the tank is the overfill prevention 83 83 83 set to activate? (Inches from bottom of tank) What is the percent capacity of the tank at which 95 95 95 the overfill prevention equipment activates? Is the overfill prevention in proper operating ® Yes ® Yes M Yes ❑ Yes condition to respond when the substance ❑ No ❑ No ❑ No ❑ No reaches the appropriate level? (Specify in section V. ) (Specify in section V. ) (Specify in section V. ) (Specify in section V. ) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS All items marked "Fail' must be explained in this section. Any additional comments may also be provided here. 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 Servi echnic n Si atur l If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting Svstem, ID = Identification, UST = Underground storage tank ICC = International Code Council, AN = Audible and visual