HomeMy WebLinkAbout12724 009491 101 12-14-2020 OFINP SLA OVERFILL INSPECTION 71959.55 OFINP
ADEM
3 YEAR OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT
Facility Name: Owner:
Address: Address:
City, County,Zip: City, State,Zip:
Facility I.D.#: Phone#:
Inspector Name: I Inspector Phone#:
Inspector Company: Inspection Date:
Instructions
1. Submit a completed copy of this form within 30 days of pedomiing lest to: Groundwater Branch,PO Box 301463,Montgomery,AL
36130-1463,or fax to: (334)270-5631,or email to: USTcompliance(3adem.alabama.00v.
2. If two or more types of overfill devices are present,only complete portion of form pertaining to the primary overfill device.
3. Inspection must be performed in accordance with a nationally recognized code of practice(such as PEI RP-1200 or equivalent)or the
manufacturers instructions.
4. Keep a copy of this inspection for 3 years. Questions on how to complete this form should be directed to the Groundwater Branch,
UST Compliance Section at(334)270-5655.
ADEM Unique Tank#
Product Stored
Primary device being used in each ❑Auto Shutoff ❑Auto Shutoff ❑Auto Shutoff ❑Auto Shutoff ❑Auto Shutoff
tank to prevent overfill (Record only ❑Alarm ❑Alarm ❑Alarm ❑Alarm ❑Alarm
primary device inspection results.) ❑Ball Float ❑ Ball Float ❑ Ball Float ❑ Ball Float ❑ Ball Float
Was primary overfill device ❑yes ❑yes ❑yes ❑yes ❑yes
removed for test? ❑no ❑no ❑no ❑no ❑no
Automatic Shutoff Device Inspection
Drop tube and float free of debris? yes ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no
Float moves freely and poppet ❑yes ❑yes ❑yes ❑yes ❑yes
moves into path of flow? ❑no ❑no ❑no ❑no ❑no
Bypass valve free of blockage? 11 D no 13❑no 13❑no 13❑no 13❑no
(where applicable) ❑Na ❑n/a ❑n/a ❑n/a ❑n/a
Flapper adjusted to shut off flow at ❑yes ❑yes ❑yes ❑yes ❑yes
95%or less capacity? ❑no ❑no ❑no ❑no ❑no
High Level Alarm Ins ection Outside Near Tanks,Not Inside at Tank Monitor
Overfill alarm activates in test ❑yes ❑yes ❑yes ❑yes ❑yes
mode at console? ❑no ❑no ❑no ❑no ❑no
Alarm can be heard and/or seen ❑yes ❑yes ❑yes ❑yes ❑yes
from where the tank is filled? ❑no ❑no ❑no ❑no ❑no
All associated floats move freely? O yes ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no
Alarm activates at 90%or less ❑yes ❑yes ❑yes ❑yes ❑yes
ca acit ? ❑no ❑no ❑no ❑no ❑no
Ball Float Valve Inspection
Ball float cage free of debris? O yes ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no
Ball moves freely in cage and is ❑yes ❑yes ❑yes ❑yes ❑yes
free of damage? ❑no ❑no ❑no ❑no ❑no
Vent hole in pipe is open and near ❑yes ❑yes ❑yes ❑yes ❑yes
the top of the tank? ❑no ❑no ❑no ❑no ❑no
Ball float pipe is proper length to ❑yes ❑yes ❑yes ❑yes ❑yes
activate at 90%or less capacity? ❑no ❑no ❑no ❑no ❑no
Tank top fittings are vapor tight ❑yes ❑yes ❑yes ❑yes ❑yes
and free of leaks? ❑no ❑no ❑no ❑no ❑no
Inspection Results for Automatic Shutoff Device or High Level Alarm or Ball Float Valve
Results of Inspection: 0 pass O pass O pass O fall pass O pass
('No"answer to any item indicates fail.) 0 fall O fall O fall O O fall
Repairs Needed Date of Repair Description of any Repairs
Tester's Signature:
ADEM Form 559 03/18 m2(revised 8/19)