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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ® 36 Month Inspection I . FACILITY INFORMATION CERS ID 10443520 Date of Overfill Prevention Equipment Inspection 19/26/ 18 Business Name (Same as Facility Name or DBA-Doing Business As.) THORNTON CHEVRON Business Site Address City ZIP Code 9015 WALNUT GROVE THORNTON) CA 95351 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # DAVEWINKLER 209 744 - 0112 Ext. Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date 08-1739 8883059-UT 1 -31-20 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW Phil-Tite & EVR Phase 1 1009853708 Ex 11 - 16- 18 OPW 104-633 Ex 3- 14-2020 Emco #3207 Ex. 09-21 -2020 VR: B34975 ATG: 2/8/20 III , OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used : [3d Manufacturer Guidelines (Spe6MEDER ROOT REMOVED PROBES ❑ Industry Code or Engineering Standard (Specify) ❑ Engineered Method (Specify) Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages: Tank ID : (By tank number, stored product, etc.) 87 91 DSL What is the tank inside diameter? (Inches) 11960 119 . 60 119 . 60 Is the fill piping secondarily contained? [3d Yes jNo ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ® Yes ❑ ® Yes ❑ No ® Yes [:] No ❑ Yes ❑ No VEEDER ROOT VEEDER ROOT VEEDER ROOT VEEDER ROOT Overfill Prevention Equipment Manufacturer(s) PROBE PROBE PROBE What is the overfill prevention equipment ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow response when activated? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow (Check all that apply.) [N AN Alarm [M AN Alarm ® AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping? ❑ Yes ® No ❑ Yes I3d No ❑ Yes ® No ❑ Yes ❑ No At what level in the tank is the overfill prevention107 107 set to activate? (Inches from bottom of tank.) 107 What is the percent capacity of the tank at which 90 90 90 the overfill prevention equipment activates? Is the overfill prevention in proper operating ® Yes IX Yes [RYes ❑ Yes condition to respond when the substance ❑ No ❑ No ❑ No ❑ No reaches the appropriate level? (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 ❑ Fail M Pass ❑ Fail EX Pass ❑ Fail ❑ Pass ❑ Fail V . COMMENTS All items marked "Fail' must be explained in this section. Any additional comments may also be provided here. �NVIRD v a D 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 may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council, AN = Audible and visual