Cal. Code Regs. Tit. 23, div. 3, ch. 16, app IX
| 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)
Cal. Code Regs. Tit. 23, div. 3, ch. 16, app IX
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.