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i <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10186995 11 /21 /2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Chevron <br /> Business Site Address city ZIP Code <br /> 1916 E . March Lane Stockton 95210 <br /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Chris Bishop 1 (916) 3824761 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 949066 82116429 5/2/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> OPW# 074929 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify): <br /> Used: OPW INSTALL INSTRUCTIONS . <br /> ❑ Industry Code or Engineering Standard (Specify): <br /> ❑ Engineered Method (Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages <br /> TANK ID: (By tank number, stored product, etc.) 87 91 DIESEL <br /> What is the tank inside diameter? (Inches) 119 . 25 119 . 25 119 . 25 <br /> Is the fill piping secondarily contained ? Z Yes ❑ No IRI Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑x Yes ❑ No ❑x Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturers) OPW 71 SO OPW 71 SO OPW 71 SO <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> (Check all that ❑x Restricts Flow ❑x Restricts Flow P9 Restricts Flow ❑ Restricts Flow <br /> apply.) <br /> ❑ AIV Alarm ❑ AIV Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 106 . 75 107 . 25 106 . 75 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? > 95 % >95% > 95% <br /> Is the overfill prevention in proper operating condition [9 Yes p Yes ❑x Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level? EINo (Specify in V.) [INo (Specify in V.) ElNo (Specify in V.) [INo (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results 0 Pass ❑ Fail Z Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail <br /> i <br /> V. COMMENTS <br /> Any items marked "Fail' must be explained in this section. Any additional comments may also be provided here. <br /> i <br /> Vl. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> 1 hereby certify that the overfill prevention a ipment was inspected in accordance with California Code of Regulations , Title 23 , <br /> Division 3, Chapter 16, Section 2637. 2 and i the i f rmation contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components than Wis frrm 915co modates, additional copies of this page maybe attached. <br />€ CERS = CatFornia Environmental Reporting System, ID = identifica on, UST = I Inderground Storage Tank, ICC = International Code Council, AA/ = Audible and Visual <br /> f <br /> E <br /> i <br />