Laserfiche WebLink
UNDERGROUNDSTORAGETANK ' <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test Repair Test W 36 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection : <br /> 10184563 2/21 /2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As . ) <br /> Chevron 212470 <br /> Business Site Address City: Zip : <br /> 3400 N MacArthur Drive Tracy 95376 <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 (800) 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 05101 /2019 <br /> 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Manufacturer Guidelines (Specify) <br /> Test Method Used : 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.) 91 87 dsl <br /> What is the tank inside diameter? (Inches) 117 .75 in . 117 . 75 in . 118 . 13 in . <br /> Is the fill piping secondarily contained ? rvo Yes r No r Yes r No W Yes r No r Yes No <br /> i <br /> Is the vent piping secondarily contained ? r Yes r No r Yes r No r Yes r No r Yes r No <br /> Overfill Prevention Equipment Manufacturer(s) <br /> other other other <br /> r Shuts Off Flow r Shuts Off Flow r Shuts Off Flow r Shuts Off Flow <br /> What is the overfill prevention equipment response r Restrict Flow r Restrict Flow r Restrict Flow r Restrict Flow <br /> when activated ? (Check all that apply . ) AA/ Alarm F AA/ Alarm AA/ Alarm r A/V Alarm <br /> Are flow restrictors installed on vent piping ? Yes r No Yes r No r Yes r No r Yes r No <br /> At what level in the tank is the overfill prevention set to 97 98 99 <br /> activate? ( Inches from bottom of tank. ) <br /> What is the percent capacity of the tank at which the 90 90 90 <br /> overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating condition W Yes r Yes r Yes r Yes <br /> to respond when the substance reaches the r No r No r No r No <br /> appropriate level ? (Spesify in section V) (Spesify in section V) (Spesify in section V) (Spesify in section V) <br /> N. SUMMARY OF TESTING RESULTS <br /> Overfill Prevention Inspection Results r Pass r Fail Pass r Fail Pass r Fail r Pass r 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 /> 1 hereby certify that the spill containers were tested in accordance with California Code of Regulations , title 23 , division 3 , chapter 16, section <br /> 2637. 1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> /L 4z <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached . <br /> Pn„irnmmnntnr RnnnrNnn Svctem_ in=Identification . UST=Underground storage tank, ICC=International Code Council <br />