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ED <br /> IJEC� <br /> W.O.# NW1-2337824 OCT 0 8 ZA Cust Ref#: COCO SO-0015267473 <br /> JAL L <br /> ff"WiTORAGE TANK <br /> OVERFILL PREVE MEM <br /> E I INSPECTION REPORT FORM(pop t of t) <br /> Type of Action installation Inspection ❑Repair Inspection 1p moo inspection <br /> I. FACILITY INFORMATION <br /> CERS ID } Date of overnp Pninfention Equipment inspection <br /> � o ! (� 1 ® —a—1 <br /> Business Name(Seam as F Nam or DSA,Daing Business As) <br /> Chevron � c`` � 0 ri <br /> Business Site Address City zl! e <br /> If. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST S Technician (Print as on IC j P # <br /> r) p" <br /> Contractor/Tank Tester License# ICCrtl on# tion Date <br /> Yi fCS <br /> fi Prevention Equipment Inspection Training and c ) <br /> III 0 ILLPREVENTION EQUIPMENT INSPECTION FIA <br /> t (S ): <br /> Used: <br /> ❑Industry Code at Engineering Standard(SRocilY): <br /> Engineered (Spec*): <br /> Attach Me Inspection procedures and all doculnentation required to defennine Me results. <br /> *of Attached Pages <br /> TANK ID.(By tank 'stowedprodwt ) +^ 3 <br /> What is tank Insirls diameter?(t s) % n c, <br /> Is the fill piping secondarilycontained? WJAes ❑Na Mes ❑No WYes ❑No ❑Y <br /> la the vent Piping secondarily t ? ❑Yes ❑Yes ❑Yes ®Yes ❑No <br /> Overfill Prevention Equip nt a s} i`t+ /` ti arl <br /> What Is the overfill prevention equipment response f^Shuts tiff Flown is Off Flow I$Shuts tiff Flow ❑Shuts Off Flow <br /> activated?when(Check all bw apply) ❑ResWcts Ft ❑Restricts Flow ❑Restricts Flow ❑Restlicts Flow <br /> ❑AMI Alarm ❑ ❑AN Alarm ❑AV Mame <br /> Are flow restridars Installed on vent piping? ❑Yes ❑No ❑Yes [I No 0 Yes ❑/N'^o ❑Yes ❑NO <br /> t levet n is p <br /> to i �✓(�° . t"3 <br /> to ?(t off k) �. <br /> overbill prevention What is the percent <br /> equipment ai ?at C d <br /> Is Me overfill prevention in Koperoperating on s ea ❑Yes <br /> torespond ' substancem the ❑No fSpeWy in V.) ❑No(Specify in V.) ❑No( kr V.) ❑No(Specify in V.)'. <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Preventiont R ss [3Fag ❑Faa ❑Fait ❑ ®Peal <br /> V. COMMENTS <br /> Any hems marked'Fad'must be explained in this secaDn. Any additional comments may also be provided hare. <br /> CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING S C N <br /> I hereby cerft that the overfill prevention equipimentwas Inspected In accordance with California Code afRegulations,Title 23, <br /> Division 3,Chapter 16,Section 2637.2 and all the Information n i herein is accurate. <br /> t&STService Technician Signature <br /> M Me ftNW has mom compollOnts res, of this pop may be affached <br /> CERS=Cdbn'eEn*—erAW ,MD= T <br /> OVERFILL INSPECTION REPORT <br />