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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT Type of Action: ❑ installation inspection ❑ Repair Inspection FORM ® 36 Month Inspection , a,I I. FACILITY INFORMATION CERS ID D i 3te of Overfill Prevention Equipment spection 12/27/2018 Business Name Chevron Business Site Address 2758 W Kettleman City Lodi Zip Code II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Service Technician (on ICC Certification) Tim Burkart Phone It 916-371-2380 Contractor License H: 433159 ICC Certification: 00210960 ICC E piration Date: Overfill Prevention Equipment Relevant Certifications (List Applicable): III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used: ❑ Manufacturer Guidelines (Specify): ® Industry Code or Engineering Standard (Specify): PEI 1200 ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results, n of attached pages: Tank ID: (By tank number, stored 87 91 D L What is the tank inside diameter? (inches) 119.50 Is the Fill Piping Secondarily contained? ® Yes ❑ No ® Yes ❑ No Yes ❑ No ❑ Yes ❑ No 0 Is the Vent Piping Secondarily contained? ® Yes ❑ No ® Yes ❑ No Yes ❑ No ❑ Yes ❑ No El Overfill Prevention Equipment Manufacturer Emco Emco Emco Tank Manufacturer What is the overfill prevention equipment response when activated? (Check all that apply) ® Shuts Off Flow ❑ Restricts Flow ❑ A/V Alarm ® Shuts Off Flow ❑ Restricts Flow ❑ A/V Alarm Shuts Off Flow Restricts Flow A/V Alarm ❑ Shuts Off Flow ❑ Restricts Flow ❑ A/V Alarm Are flow restrictors installed on vent piping? ❑ Yes ® No ❑ Yes ® No El Yes ® No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 102" 101" 103" What Is the percent capacity of the tank at which the overfill prevention equipment activates? 92 94 94 Is the overfill prevention in proper operating condition to respond when the substance reaches the appropriate level? ® Yes ❑ No (Specify in V.) ® Yes ❑ No (Specify in V.) El E Yes I No (Specify In V.) ❑ Yes ❑ No (Specify in V.) IV, SUMMARY OF INSPECTION RESULT Overfill Prevention Inspection Results ® Pass ❑ Fail I ® Pass ❑ Fail Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked 'Fair' must be explained in this section. Any additional comments may also be provide here. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTI VG THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected In accordance with California Division 3, Chapter 16, Section 2637.2 and all the information contained herein is accurate Code of Regulations, Title 23, UST Service Technician Signature --