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W.0.# NW1-2337821 <br /> <br />Cust Ref#: COCO SO-0015267473 <br />UNDERGROUND STORAGE TANK <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Pats 1 of 1) I <br />Type of Action 0 Installation Inspection 0 Repair Inspection ti66 Month Inspection <br />I. FACILITY INFORMATION <br />CERS ID <br />1 0 I gi sGi 1 Date of Overfill Prevention Equipment frispection <br />Fad N, Business Name (Same as Fadli Name or Oat -Doing Business As) <br />g--\ I f or\ 192 & <br />Business Site Address <br />(0 Litk F ( J6 * r_v--\ r..( <br />City <br />''-').- k r- 'Al c n CA <br />ZIP Code <br />1_111 S. <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Up Service Technician performing the Inspection (Print as shown on the ICC Certification.) <br />if,, 2 ck t, <br />Phone it <br />Contractorl Tank Taste License it <br />Overfill Prevention Equipment Inspection Training and CeDcations (List applicable certifications) <br />ICC Certification it ICC Certification Expiration Date <br />ci / 2. Atiti- <br />7S I) <br />III,. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />Used: <br />pranufacturer Guidelines (Specify) <br />0 Industry Code or Engineering Standard (Specify): <br />0 Engineered Method (Specify): <br />Attach the Inspection procedures and all documentation required to determine <br />— <br />the results. # of Attached Pages <br />TANK ID: (By tank number, stored product. etc.) !-E )c.., ,., , 4 0. '` c' .' i 11 r. i` <br />What is the tank inside diameter? (inches) kt7, <br />Is the fill piping secondarily contained? 0 Yes KA?, 0 Yes TAo 0 Yes 0 No 0 Yes 0 No <br />Is the vent piping secondarily contained? 0 Yes IP14.0 0 Yes Ykisio 0 Yes 0 No 0 Yes 0 No <br />Overfill Prevention Equipment Manufacturer(s) 0 ? t-&) CYP Li <br />What is the overfill prevention equipment response <br />when activated? <br />(Check ail that apply.) <br />IRSchuts Off Flow <br />0 Restricts Flow <br />0 AN Alarm <br />gir(huts Off Flow <br />0 Restricts Flow <br />0 AN Alarm <br />0 Shuts Off Flow <br />0 Restricts Flow <br />0 AN Alarm <br />0 Shuts Off Flow <br />0 Restricts Flow <br />0 NV Alarm <br />Are flow restrictors installed on vent piping? 0 Yes gpe 0 Yes VP/ 0 Yes 0 No 0 Yes 0 No <br />Al what level in the tank Is the overfill prevention set <br />to activate? (Inches from bottom of tank.) 1 (t \ 1 C.C., • LA OCY <br />What Is the percent capacity of the tank at which the <br />overfill prevention equipment activates? cic., "A> i /e <br />Is the overfill prevention in proper operating condition <br />to respond when the substance reaches the <br />appropriate level? <br />PACs <br />0 No (Specify in V.) <br />irgi'es <br />0 No (Specify in V.) <br />0 Yes <br />0 No (Specify in V.) <br />0 Yes <br />0 No (Specify in V.) <br />IV. SUMMARY OF INSPECTION RESULTS <br />Overfill Prevention Inspection Results .1.4(Pass 0 Fail 1 0 Pass 0 Fail I 0 Pass 0 Fail 0 Pass 0 Fail <br />V. COMMENTS <br />Any items marked 'Far 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 equipment was inspected In accordance with California Code of Regulations, Tide 23, <br />Division 3, Chapter 16, Section 2637.2 and all the Information contained herein Is accurate. <br />UST Savior Technician Sigrere <br />1-1, Y -v.s.-.1L1 <br />defy his mon components than this form accommodates, additional copies of this page may be attached. <br />CEPS = CaBonia Environmental Repotting Sysksm, ll = Identical°, t UST = Underground Storage Tark KC = International Code Court. AN Aucthie arid Visual <br />Overfill inspection report