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N the facility has more components than this form accommodates, additional copies of this page may be IN UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action ❑ Installation Inspection ❑ Repair Inspection ® 36 Month Inspection 1. FACILITY INFORMATION CERS ID 10186665 Date of Overfill Prevention Equipment Inspection 11 /27/18 Business Name (Same as Facility Name or DBA -Doing Business As.) chevron # 307709 Business Site Address City 10858 Trinity Pkvvy Stockton ZIP Code 95219 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) T Timothy Elebeck Phone # 209 365-1246 Ext. Contractor/Tank Tester License # 743160 ICC Certification # ICC Certification Expiration Date 1 1-26-2 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) ' OPW EVR Phase 1101461 1�3�20 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used:(p (Specify) ® Manufacturer Guidelines S eci OPW �?-�i .; ❑ Industry Code or Engineering Standard (Specify) ❑ Engineered Method (Specify) Attach the inspection procedures and all documentation required to determine the results. of Attached-P�ges,n 3 Tank ID: (By tank number, stored product, etc.) T1 -Regular T2 Supreme T3 Diesel What is the tank inside diameter? (Inches) Is the fill piping secondarily contained? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? El Yes ❑ No ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) 'What OPW OPW OPW is the overfill prevention equipment response when activated? (Check all that apply.) ® Shuts Off Flow ❑ Restricts Flow ❑ AtV Alarm ® Shuts Off Flow ❑ Restricts Flow ❑AIV Alarm ® Shuts Off Flow ❑ Restricts Flow ❑ AN Alarm ❑ Shuts Off Flow ❑ Restricts Flow ❑ AN Alarm Are flow restrictors installed on vent piping? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 105 105 106 What is the percent capacity of the tank at which the overfill prevention equipment activates? 94 94 94 Is the overfill prevention in proper operating condition to respond when the substance reaches the appropriate level? ® Yes ❑ No (Specify in section V.) ® Yes ❑ No (Specify in section V.) ® Yes ❑ No (Specify in section V) ❑ Yes ❑ No (Specify in section V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ® Pass ❑ FF it ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑Fail V. COMMENTS All items marked "Fail" must be explained in this section. Any additional comments may also be provided here. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2637.2 and all the information contained herein is accurate. UST Service Technician Signature�� attached.