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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181363 10/3/2018 Business Name (Same as Facility Name or DBA -Doing Business As) Charter Way Petroleum - CHARTER WAY CHEVRON Business Site Address City ZIP Code 508 W CHARTER WAY STOCKTON, CA 95206 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Felix Ramirez (209) 744-0112 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 08-1740 3-31-20 8883072 -UT 11/22/2018 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF -FF- EBW , PhikTite & EVR Phase 1 1009883708 EX 11-16-18 OPW 104-634 Ex 3-14-202.0, pv, J— T y Emco 3147 Ex. 9-21-20 VR: B34976 ATG: 7/7/20 T, III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method 0 Manufacturer Guidelines (Specify): JAN 0 4 2019 Used: REMOVED DROP TUBES ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 3 TANK ID: (By tank number, stored product, etc.) 87 91 87 What is the tank inside diameter? (Inches) 112 112 112 Is the fill piping secondarily contained? E Yes 0 No ❑ Yes i] No ❑ Yes E No ❑ Yes ❑ No Is the vent piping secondarily contained? 0 Yes ❑ No 0 Yes ❑ No E Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) oPw OPW OPw 71-50 61-50 71-50 What is the overfill prevention equipment response Ex Shuts Off Flow x❑ Shuts Off Flow ❑x Shuts Off Flow ❑ Shuts Off Flow when activated? ❑ (Check all that apply.) ❑ Restricts Flow Restricts Flow El Restricts Flow El Restricts Flow ❑ AN Alarm ❑ AIV Alarm ❑ AIV Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping? E Yes ❑x No ❑ Yes H No ❑ Yes ❑x No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 101.5 101 101 What is the percent capacity of the tank at which the overfill prevention equipment activates? 95% 950jo 950o Is the overfill prevention in proper operating condition Ex Yes ❑x Yes ❑x Yes ❑ Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results (] Pass E1 Fail ❑x Pass ❑Fail I Z Pass ❑Fail ❑Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. VI. 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 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page maybe attached. CERS = California Environmental Reporting System, ID =Identification, UST =Underground Storage Tank, ICC = Intemafional Code Coundl, AN =Audible and Vi sual