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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection Z 36 Month inspection <br /> L FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10184725 12/28/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Chevron <br /> Business Site Address City ZIP Code <br /> 2615 West Grant Line Road Tracy 95304 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Frank Amestoy (800) 339-9930 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 804904 8374998 11 /14/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> Veeder-root B46603 <br /> 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑ Manufacturer Guidelines (Specify): <br /> Used : <br /> I] Industry Code or Engineering Standard (Specify) : PEI-1200 <br /> ❑ Engineered Method (Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 0 <br /> TANK ID: (By tank number, stored product, etc.) T1 : 91 T2: Diesel T3 : 87 <br /> What is the tank inside diameter? (Inches) 89675" 90 .25" 117.75" <br /> Is the fill piping secondarily contained? 0 Yes ❑ No El Yes ❑ No 9 Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? 9 Yes ❑ No 9 Yes ❑ No p Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) Veader-root Veeder-root Veeder-root <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> 0 AfV Alarm [9 AIV Alarm ❑x A/V Alarm ❑ AIV Alarm <br /> Are flow restrictors installed on vent piping? x❑ Yes ❑ No 0 Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No <br /> At what level In the tank Is the overfill prevention set <br /> to activate? (inches from bottom of tank.) 75.50" 76.00" 99.25" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90% 90% 90% <br /> Is the overfill prevention in proper operating condition ® Yes p Yes 0 Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass ❑ Fail 0 Pass ❑ Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. <br /> Vl . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THiS INSPECTION <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations, Title 23, <br /> Division 3, Chapter 16, Section 2637.2 and all the information contained herein is accurate. <br /> UST Service Technician Sig r <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Cafifomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Coundl, AW Audible and Visual <br /> UN-109 www.unidocs.org 111 - Rev. 06/14/16 <br /> r <br />