California Code of Regulations › Title 23 - Waters › Division 3 - State Water Resources Control Board and Regional Water Quality Control Boards › Chapter 16 - Underground Tank Regulations › Appendix IX - Underground Storage Tank Overfill Prevention Equipment Inspection Report Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
TYPE OF ACTION
[]
						  Installation
[] Repair
[] 36 Month
1. FACILITY INFORMATION
CERS ID
Inspection Date
___________________________
Facility Name
___________________________
Facility Address
City
ZIP Code
___________________________
2. SERVICE TECHNICIAN INFORMATION
Company Performing the Test
Phone
___________________________
Mailing Address
___________________________
Service Technician Performing
						  Inspection
___________________________
Contractor/Tank Tester License
						  Number
___________________________
ICC Number
Expiration Date
___________________________
3. TRAINING AND CERTIFICATIONS
Manufacturer and Test Equipment Training
						  Certifications
Expiration
						  Date
___________________________
___________________________
___________________________
___________________________
4. TEST PROCEDURE INFORMATION
Test Procedures
						  Used
Components
						  Inspected
___________________________
___________________________
___________________________
___________________________
5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING
				  INSPECTION
I hereby certify that the OPE was inspected in
				  accordance with California Code of Regulations, title 23, division 3, chapter
				  16, section
				  2637.2; that required supporting
				  documentation is attached; and all information contained herein is accurate. I
				  understand that test procedures shall be made available upon request by the
				  governing authority.
Service Technician Signature
Date
Total
						  # of Pages
___________________________
CERS = California Environmental Reporting System, ID =
				  Identification, ICC = International Code Council, OPE= Overfill Prevention
				  Equipment
6. OVERFILL PREVENTION EQUIPMENT DETAILS
Tank ID
(one OPE per
						  column)
Are both vent and tank riser piping secondarily
						  contained?
[] Yes
[] Yes
[] Yes
[] Yes
[] No
[] No
[] No
[] No
OPE Model
What is the OPE response when
[] Shut off
						  Flow
[] Shut off Flow
[] Shut off Flow
[] Shut off
						  Flow
activated?
[] Restricts Flow
[]
						  Restricts Flow
[] Restricts Flow
[] Restricts Flow
(Check all that apply.)
[]
						  Audible Alarm
[] Audible Alarm
[] Audible Alarm
[]
						  Audible Alarm
[] Visual Alarm
[] Visual
						  Alarm
[] Visual Alarm
[] Visual Alarm
Are flow restrictors installed on
[]
						  Yes
[] Yes
[] Yes
[] Yes
vent piping that may interfere
[] No
[] No
[] No
[] No
with the OPE operation?
At what level in the tank is the OPE set to activate?
(Inches from bottom of tank)
What is the percent capacity of the tank at which the
						  OPE activates?
Is the OPE in proper operating condition
[]
						  Yes
[] Yes
[] Yes
[] Yes
to respond when the stored substance
[]
						  No
[] No
[] No
[] No
reaches the designated regulatory level?
7. SUMMARY OF TESTING RESULTS
OPE Inspection Results
[] Pass
[]
						  Pass
[] Pass
[] Pass
[] Fail
[] Fail
[]
						  Fail
[] Fail
8. COMMENTS
Describe all results marked "Fail" and each proposed
				  remedy.
* Mark here if:
[] Flow restrictors interfere with overfill prevention and
				  equipment repairs required.
Additional copies of this page may be
				  attached.
Attach tank chart(s), measurements, calculations, and
				  In-Tank Setup report(s)
1. New
				  Appendix IX filed 8-27-2018; operative 10-1-2018 (Register 2018, No.
				  35).
2. Repealer and new appendix filed 8-27-2020; operative
				  10-1-2020 (Register 2020, No. 35). Filing deadline specified in Government Code
				  section
				  11349.3(a)
				  extended 60 days pursuant to Executive Order N-40-20 and an additional 60 days
				  pursuant to Executive Order N-66-20.