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4/1 /2019 TANCS PRODUCTION <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action (— Installation Test (— Repair Test r 36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection : <br /> 10186665 3/20/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As . ) <br /> CHEVRON 307709 <br /> Business Site Address City: Zip: <br /> 10858 TRINITY PKWY STOCKTON 95219 <br /> II , UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test ( Print as shown on the ICC Certification , ) Phone # <br /> Jesus Saldivar (600) 8004633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8361393 6/16/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Veeder Root - VR Level 4 B45334 05/01 /2019 <br /> 111 . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Manufacturer Guidelines (Specify) Veeder Root <br /> Test Method Used : r Industry Code or Engineering Standard (Specify) PEI RP 1200 <br /> 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.) T1 T-2 T-3 <br /> What is the tank inside diameter? ( Inches) 117 .75 in . 117 .75 in . 118 .38 in . <br /> Is the fill piping secondarily contained ? Yes — No Yes — No ✓ Yes — No — Yes — No <br /> Is the vent piping secondarily contained ? — — ✓ — — — <br /> P P 9 Y Yes No Yes No Yes No Yes No <br /> Unknown Unknown Unknown <br /> Overfill Prevention Equipment Manufacturer(s) <br /> other other other <br /> (— Shuts Off Flow Shuts Off Flow (— Shuts Off Flow �_ Shuts Off Flow <br /> What is the overfill prevention equipment response (— Restrict Flow Restrict Flow r Restrict Flow ( Restrict Flow <br /> when activated ? (Check all that apply. ) (✓ A/V Alarm A/V Alarm A/V Alarm A/V 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 to 99 96 100 <br /> f; activate? ( Inches from bottom of tank. ) <br /> What is the percent capacity of the tank at which the 90 89 90 <br /> overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating condition Yes Yes Yes — Yes <br /> to respond when the substance reaches the appropriate — No — No — No — No <br /> level? (Specify in section V) Spesify in section V) [Spesify in section V) ISpesify In section V) <br /> IV, SUMMARY OF TESTING RESULTS <br /> Overfill Prevention Inspection Results Pass — Fail ✓ Pass — Fall ✓ Pass — Fail — Pass — 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 /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 23, division 3 , chapter 16, <br /> section 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=ldentifl cation , UST=Underground storage tank , ICC= International Code Council <br /> https://tancs .tanknology.comrrANCS .aspx?5681947916630 1 /1 <br />