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1. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspect ion 10112f2018 Business Name (Same as Facility !Name or DBA -Doing Business As.) CHEVRON Business Site Address City ZlF' Code 6633 PACIFIC AVENUE STOCKTON 95207 IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # GREG KAISER 209 887 - 2639 Ext. Contractorfrank Tester License # ICC Certification # ICC Certification Expiration Date 859535 5252318 411112019 Overfill Prevention Equipment inspection Training and Certifications (List applicable certifications.) Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used: 0 Manufacturer Guidelines (Specify) ❑ Industry Code or Engineering Standard (Specify) ❑ Engineered Method (Specify) Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages: 9 Tank ID: (By tank number, stored product etc.) T1 Super T2 Regular 1 T3 Re alar 2 What is the tank inside diameter? (inches) 90.88 90.88 90.88 Is the fill piping secondarily contained? CxI Yes ❑ No 0 Yes ❑ No 9 Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? D Yes ❑ No 0 Yes ❑ No 0 Yes [I No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) Auto Limiter It Auto Limiter 11 Auto Limiter II What is the overfill prevention equipment ❑x Shuts Off Flow 0 Shuts Off Flow 0 Shuts Off Flow Q Shuts Off Flow response when activated? (check all that apply.), ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restficts Flow ❑ AN Alarm ❑ AIV Alarm ❑ AN Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping? ❑ Yes 0 No ❑ Yes D No El Yes 9 No ❑ Yes ❑ No. At what level in the tank is the overfill prevention set to activate? (inches from bottom of tank.) $1 �'$ 81 314 81 114 What is the percent capacity of the tank at which the overfill prevention equipment activates? 94.4% 94.5% 94% Is the overfill prevention in proper operating 19 Yes IN Yes 0 Yes ❑ Yes condition to respond when the substance ❑ No ❑ No reaches the appropriate level? © No ❑ No (Specify in section V.} (Specify in section V.) (Specify in section V.) (Specify in section V:) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results(] Pass El Fail 0 Pass ❑Fail (� pass ©Fail ❑ pass OF 71 V. %.Vn nt:N I U All items marked "Fail- must be explained in this section. Any additional comments may also be provided here. Vl. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations, title 23, division 3, ' chapter 16, section 2637.2 an all the inform on contained herein is accurate. UST Service Techni Sin lirn if the facilit has 0 Y ponents than this form accommodates, additional copies of oris page may be attached. CERS = California En ' rita Iting SYS IC = ntifi�tion, UST = Underground stot8ge tank, ICC = Intematbrial Code Counal. AN=Audble and visuai