Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page -I of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 12/ 13/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Flyers #427 <br /> Business Site Address City ZIP Code <br /> 3300 Waterloo Road Stockton 95205 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Anthony Reyes ( 916 ) 373 - 1166 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 617238 8293772 9/ 16/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> OPW UST Phase 1 EVR Tech# 103920 - F _l k� <br /> B LL <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION IN R bit Y <br /> Inspection Method p Manufacturer Guidelines (specify) : <br /> Used : OPW Install & Maintenance Guidelines DEC 2 1 N <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> 0H <br /> ❑ Engineered Method (Specify): DEPARTMENT <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages <br /> TANK ID : (By tank number, stored product, etc.) Red Diesel <br /> What is the tank inside diameter? (Inches) 95 <br /> Is the fill piping secondarily contained? ❑ Yes ❑ No ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes ❑ No ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) oPw <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ❑x Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) Restricts Flow El Restricts Flow El Restricts Flow El Restricts Flow <br /> ❑ AN Alarm ❑ AN Alarm ❑ AIV Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes ❑ No ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 83 . 625 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 92 % <br /> Is the overfill prevention in proper operating condition ❑ Yes z Yes ❑ Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level ? ❑ No (Specify in V) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑ Pass E] Fail Q Pass El Fail El Pass E] Fail E] Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here . <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations , Title 233 <br /> Division 3 , Chapter 16 , Section 2637 . 2 and all the information contained herein is accurate . <br /> UST Service Technician Signature n <br /> If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Usual <br />