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Appendix IX Underground Storage Tank Overfill Prevention Equipment Inspection Report Form

23 CA ADC Div. 3 Ch. 16 App. IXBarclays Official California Code of Regulations

Barclays 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
23 CCR Div. 3 Ch. 16 App. IX
Appendix IX Underground Storage Tank Overfill Prevention Equipment Inspection Report Form
Currentness
TYPE OF ACTION
Empty Checkbox​ Installation
Empty Checkbox​ Repair
Empty Checkbox​ 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?
Empty Checkbox​ Yes
Empty Checkbox​ Yes
Empty Checkbox​ Yes
Empty Checkbox​ Yes
Empty Checkbox​ No
Empty Checkbox​ No
Empty Checkbox​ No
Empty Checkbox​ No
OPE Model
What is the OPE response when
Empty Checkbox​ Shut off Flow
Empty Checkbox​ Shut off Flow
Empty Checkbox​ Shut off Flow
Empty Checkbox​ Shut off Flow
activated?
Empty Checkbox​ Restricts Flow
Empty Checkbox​ Restricts Flow
Empty Checkbox​ Restricts Flow
Empty Checkbox​ Restricts Flow
(Check all that apply.)
Empty Checkbox​ Audible Alarm
Empty Checkbox​ Audible Alarm
Empty Checkbox​ Audible Alarm
Empty Checkbox​ Audible Alarm
Empty Checkbox​ Visual Alarm
Empty Checkbox​ Visual Alarm
Empty Checkbox​ Visual Alarm
Empty Checkbox​ Visual Alarm
Are flow restrictors installed on
Empty Checkbox​ Yes
Empty Checkbox​ Yes
Empty Checkbox​ Yes
Empty Checkbox​ Yes
vent piping that may interfere
Empty Checkbox​ No
Empty Checkbox​ No
Empty Checkbox​ No
Empty Checkbox​ 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
Empty Checkbox​ Yes
Empty Checkbox​ Yes
Empty Checkbox​ Yes
Empty Checkbox​ Yes
to respond when the stored substance
Empty Checkbox​ No
Empty Checkbox​ No
Empty Checkbox​ No
Empty Checkbox​ No
reaches the designated regulatory level?
7. SUMMARY OF TESTING RESULTS
OPE Inspection Results
Empty Checkbox​ Pass
Empty Checkbox​ Pass
Empty Checkbox​ Pass
Empty Checkbox​ Pass
Empty Checkbox​ Fail
Empty Checkbox​ Fail
Empty Checkbox​ Fail
Empty Checkbox​ Fail
8. COMMENTS
Describe all results marked “Fail” and each proposed remedy.
* Mark here if:
Empty Checkbox​ 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)

Credits

History
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.
This database is current through 4/26/24 Register 2024, No. 17.
Cal. Admin. Code tit. 23, Div. 3 Ch. 16 App. IX, 23 CA ADC Div. 3 Ch. 16 App. IX
End of Document