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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action ❑ Installation Inspection ❑ Repair Inspection 0 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10180605 1/29/19 Business Name (Same as Facility Name or DBA -Doing Business As) FLAG CITY CHEVRON Business Site Address City ZIP Code 6421 Capital Ave I Lodi 95242 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Edward Stearns (209) 744-0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 14-1760 Ex. 09/30/2020 8883080 -UT 11/9/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , PhikTite & EVR Phase 1 1009893708 Ex 11/29/2020 OPW 104-635 Ex 3-14-2020 Emco 3205 Ex. 11/16/2020 ATG: VR A31048 Ex.8/9/19 Incon 1009893708 11/30/2020 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method El Manufacturer Guidelines (Specify): remove and inspected Used: ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 TANK ID: (By tank number, storedproduct, etc.) 91 87 MASTER 87 SLAVE DIESEL What is the tank inside diameter? (Inches) 96 96 96 96 Is the fill piping secondarily contained? ❑ Yes x❑ No ❑ Yes EINo ❑ Yes H No ❑ Yes Z No Is the vent piping secondarily contained? ❑ Yes N No ❑ Yes E]No ❑ Yes Z No ❑ Yes N No Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW OPW 61 SO 61 SO 61 SO 61 SO What is the overfill prevention equipment response❑x Shuts Off Flow [] Shuts Off Flow ❑x Shuts Off Flow Z Shuts Off Flow when activated? (Check all that apply) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ A/V Alarm ❑ A/V Alarm ❑ AIV Alarm ❑ A/V Alarm Are flow restrictors installed on vent piping? ❑ Yes H No ❑ Yes ❑X No ❑ Yes [E No ❑ Yes ❑x No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 85 80.00 80.00 80.00 What is the percent capacity of the tank at which the overfill prevention equipment activates? 97 93 93 93 Is the overfill prevention in proper operating condition ❑x Yes 0 Yes (] Yes ❑x 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 ❑x Fail E] Pass ❑ Fail Z Pass ❑ Fail ❑x Pass ❑ Fail V. COMMENTS Any items marked "Fail' must be explained in this section. Any additional comments maj#j'alse providgd here. 91 DROP TUBE FLAPPER SET TO HIGH. z i{ ! p ggnn VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipmentwas inspected in accordance wry 6hr11fCot1hIh/t19djbjof 2d, rl irO s, Title 23, Division 3, Chapter 16, Section 2637.2 and all the information contained herein is accurate.,- r � ,� rr psi_ 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 = International Code Council, AA/ Audible and Usual