HomeMy WebLinkAboutOPI 5-1-19 #2CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, A/V = Audible and Visual
UNDERGROUND STORAGE TANK
OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1)
Type of Action Installation Inspection Repair Inspection 36 Month Inspection
I. FACILITY INFORMATION
CERS ID Date of Overfill Prevention Equipment Inspection
Business Name (Same as Facility Name or DBA-Doing Business As)
Business Site Address City ZIP Code
II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION
Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone #
Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date
Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.)
III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION
Inspection Method
Used: Manufacturer Guidelines (Specify):
Industry Code or Engineering Standard (Specify):
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.)
What is the tank inside diameter? (Inches)
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
Overfill Prevention Equipment Manufacturer(s)
What is the overfill prevention equipment response
when activated?
(Check all that apply.)
Shuts Off Flow Shuts Off Flow Shuts Off Flow Shuts Off Flow
Restricts Flow Restricts Flow Restricts Flow Restricts Flow
A/V Alarm A/V Alarm A/V Alarm A/V 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 set
to activate? (Inches from bottom of tank.)
What is the percent capacity of the tank at which the
overfill prevention equipment activates?
Is the overfill prevention in proper operating condition
to respond when the substance reaches the
appropriate level?
Yes Yes Yes Yes
No (Specify in V.) No (Specify in V.) No (Specify in V.) No (Specify in V.)
IV. SUMMARY OF INSPECTION RESULTS
Overfill Prevention Inspection Results Pass Fail Pass Fail Pass Fail Pass Fail
V. COMMENTS
Any 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 Service Technician Signature
If the facility has more components than this form accommodates, additional copies of this page may be attached.