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k , <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test Repair Test 36 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection : <br /> 10181655 10/2/2018 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> Chevron 372736 <br /> Business Site Address City: Zip : <br /> 9484 West Lane Stockton 95210 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test ( Print as shown on the ICC Certification . ) Phone # <br /> Edwin Pineda (800) 8004633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8373052 6/26/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> ICC - CA UST Service Technician 8373052 06/26/2019 <br /> 111, OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Manufacturer Guidelines (Specify) OPW <br /> Test Method Used : F Industry Code or Engineering Standard (Specify) PEI RP 1200 <br /> r 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.) Diesel <br /> What is the tank inside diameter? ( Inches) 92 . 00 in . <br /> Is the fill piping secondarily contained ? W Yes r No r Yes r No r Yes r No r Yes r No <br /> Is the vent piping secondarily contained ? r Yes W No r Yes r No r Yes r No Yes r No <br /> Unknown <br /> Overfill Prevention Equipment Manufacturer(s) <br /> OPW <br /> P Shuts Off Flow r Shuts Off Flow Shuts Off Flow r Shuts Off Flow <br /> i What is the overfill prevention equipment response <br /> F Restrict Flow Restrict Flow Restrict Flow Restrict Flow <br />[ when activated ? (Check all that apply. ) r A/V Alarm r AA/ Alarm AA/ Alarm AA/ Alarm <br /> Are flow restrictors installed on vent piping ? r Yes F 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 81 . 125 <br /> activate? ( Inches from bottom of tank. ) <br /> What is the percent capacity of the tank at which the 95 % <br /> overfill prevention equipment activates ? <br /> Is the overfill prevention in proper operating condition Yes Yes r Yes Yes <br /> to respond when the substance reaches the No No r No r No <br /> appropriate level ? (Spesify in section V) (Spesify in section V) (Spesify in section V) (Spesify in section V) <br /> IV SUMMARY OF TESTING RESULTS <br /> k <br /> Overfill Prevention Inspection Results r 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 /> We were unable to remove the drop tubes on the 87 and 91 tanks This will require a return visit They were measured in place to check for proper <br /> placement. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> 1 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 />