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UNDERCROUNDSTORAGETANK' <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />Type of Action � Installation Test � Repair Test � 36 Month Test <br />I. FACILITYINFORMATION <br />CERS ID <br />10186665 <br />Date of Overfill Prevention <br />3/20/2019 <br />Equipment Inspection: <br />Business Name (Same as Facility Name or DBA -Doing Business As.) <br />CHEVRON 307709 <br />Business Site Address <br />10858 TRINITY PKWY <br />City: <br />STOCKTON <br />Zip: <br />95219 <br />ll. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) <br />Jesus Saldivar <br />Phone # <br />(800) 800-4633 <br />Contractor/Tank Tester License # <br />Class A General Engineering 743160 <br />ICC Certification # <br />8361393 <br />ICC Certification Expiration Date <br />6/16/2019 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Veeder Root - VR Level 4 845334 05/01 /2019 <br />111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Manufacturer Guidelines (Specify) Veeder Root <br />Test Method Used: � Industry Cade or Engineering Standard (Specify) PEI RP 1200 <br />Engineered Method (Specify) <br />Attach the testing procedures and all documenfation required fo determine the results. <br /># of <br />1 <br />Attached Pages: <br />Tank ID: (ey tank number, stored product, etc.) <br />T1 <br />T-2 <br />T-3 <br />What is the tank inside diameter? (Inches) <br />117.75 in. <br />117.75 in. <br />118.38 in. <br />Is the fill piping secondarily contained? <br />r Yes � No <br />� Yes � No <br />� Yes � No <br />� Yes � No <br />Is the vent piping secondarily contained? <br />� Yes r No <br />� Yes � No <br />� Yes r No <br />� Yes � No <br />Overfill Prevention Equipment Manufacturers) <br />Unknown <br />Unknown <br />Unknown <br />other <br />other <br />other <br />What is the overfill prevention equipment response <br />when activated? (Check all that apply.) <br />Shuts Off Flow <br />�? Restrict Flow <br />A/V Alarm <br />�' Shuts Off Flow <br />Restrict Flow <br />� AN Alarm <br />� Shuts Off Flow <br />C` Restrict Flow <br />A/V Alarm <br />� Shuts Off Flow <br />Restrict Flow <br />� AIV Alarm <br />Are flow restrictors installed on vent piping? <br />� Yes � No <br />� Yes � No <br />r Yes � No <br />r Yes � No <br />At what level in the tank is the overfill prevention set to <br />activate? (Inches from bottom of tank.) <br />99 <br />gg <br />100 <br />What is the percent capacity of the tank at which the <br />overfill prevention equipment activates? <br />90 <br />gg <br />90 <br />Is the overfill prevention in proper operating condition <br />to respond when the substance reaches the <br />appropriate level? <br />� Yes <br />r No <br />(Spesify in section V) <br />� Yes <br />� No <br />(Spesify in section V) <br />� Yes <br />� No <br />(Spesify in section V) <br />r Yes <br />r No <br />(Spesify in section V) <br />N, SUMMARY OF TESTING RESULTS <br />Overfill Prevention Inspection Results <br />� Pass � Fail <br />� Pass � Fail <br />r Pass � Fail <br />� 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 <br />2637.1 and all the information contained herein is accurate. <br />3, chapter 16, section <br />UST Service Technician Signature <br />If the facility has more components than this form accommodates, additional copies of this page may ae attacnen. <br />CERS=California Environmental Reporting System, ID=Identification, UST=Underground storage tank, ICC=International Code Council <br />