Cal. Code Regs. Tit. 23, div. 3, ch. 16, app IX - Underground Storage Tank Overfill Prevention Equipment Inspection Report Form

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)

Notes

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

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.

1. New Appendix IX filed 8-27-2018; operative 10/1/2018 (Register 2018, No. 35).