Laserfiche WebLink
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 /> 10186665 1 11 /27/ 18 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> chevron # 307709 <br /> Business Site Address City ZIP Code <br /> 10858 Trinity Pkwy Stockton 95219 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification. ) Phone # <br /> Timothy Elebeck 209 365 - 1246 Ext. <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 743160 1 8001435 1 -26-20 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications. ) <br /> OPW EVR Phase 1101461 1 �3m20 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: ® Manufacturer Guidelines (Specify) OPW <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.) Tl-Regular T2 Supreme T3 Diesel <br /> What is the tank inside diameter? (Inches) <br /> Is the fill piping secondarily contained? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ® Yes ❑ No ED Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No <br /> OPW OPW OPW <br /> Overfill Prevention Equipment Manufacturer(s) <br /> What is the overfill prevention equipment ® Shuts Off Flow ® Shuts Off Flow ® Shuts Off Flow ❑ Shuts Off Flow <br /> response when activated? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) ❑ AN Alarm ❑ A/V 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 105 105 106 <br /> set to activate? (Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which 94 94 94 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating ® Yes ® Yes ® Yes ❑ Yes <br /> condition to respond when the substance ❑ No ❑ No ❑ No ❑ No <br /> reaches the appropriate level? (Specify in section V. ) (Specify in section V . ) (Specify in section V. ) (Specify in section V. ) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> All items marked 'Fail" must be explained in this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations , title 23 , division 3, <br /> chapter 16 , section 2637 .2 and all the Infonnation contained herein is accurate. <br /> UST Service Technician Signature <br /> N the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = CaWomia Environmental Reporting System, ID = Ids' rcabon, UST = Underground s6orage tank, ICC = International Code CouicC AN = Audible and visual <br />