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UNDERGROUNDSTORAGETANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page 1 of 1) <br /> Type of Action r Installation Test r Repair Test W 36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection: <br /> 10182331 1 2/7/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> CHEVRON 208118 N-4087-1-3 <br /> Business Site Address City: Zip: <br /> 3355 E. HAMMER LANE @ HOLMAN RD STOCKTON 95212 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> Clint Fuhrman (800)800-4633 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Class A General Engineering 743160 9160945 5/2/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> Franklin Fueling-Phil-Tite EVR Ph 1 Systems 1011093711 05/21/2021 OPW-EVR Phase 1 904272 05/23/2021 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> WO Manufacturer Guidelines(Specify) OPW <br /> Test Method Used: r Industry Code or Engineering Standard (Specify) PEI RP 1200 <br /> Engineered Method (Specify) <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages: <br /> 1 <br /> Tank ID: (By tank number, stored product, etc.) T1 T2 <br /> What is the tank inside diameter?(Inches) 117.75 in. 117.75 in. <br /> Is the fill piping secondarily contained? r Yes F No r Yes F No r Yes r No r Yes r No <br /> Is the vent piping secondarily contained? r Yes F No r Yes FV No r Yes r No r Yes r No <br /> Unknown Unknown <br /> Overfill Prevention Equipment Manufacturer(s) <br /> OPW OPW <br /> WO Shuts Off Flow W Shuts Off Flow r Shuts Off Flow r Shuts Off Flow <br /> when act <br /> What cthe overfill prevention equipment response r Restrict Flow r Restrict Flow r Restrict Flow r Restrict Flow <br /> activated?(Check all that apply.) r A/V Alarm r AA/Alarm r A/V Alarm r AN Alarm <br /> Are flow restrictors installed on vent piping? r Yes r No r Yes r No r Yes r No r Yes r No <br /> At what level in the tank is the overfill prevention set to 103.375 103.25 <br /> activate?(Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which the 94 94 <br /> overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating condition Yes F%O- Yes r Yes r Yes <br /> to respond when the substance reaches the r No r No r No r No <br /> appropriate level? (Specify in section V) (Specify in section V) (Specify in section V) (Specify in section V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Overfill Prevention Inspection Results F Pass r Fail r Pass r Fail r Pass r Fail r Pass r Fail <br /> V. COMMENTS <br /> All items marked failed above must be explained in this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations,title 23,division 3,chapter 16,section <br /> 2637.1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council <br />