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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection E 36 Month _ Inspection <br /> i . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10180605 W11111 /29/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> FLAG CITY CHEVRON <br /> Business Site Address Aaaaode <br /> 6421 Capital Ave Wj §Lv42 <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 /> Edward Stearns ( 209 ) 744 - 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14= 1760 Ex . 09/30/2020 8883080- UT 11 /9/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- EBW , PhikTite & EVR Phase 1 1009893708 Ex 11 /29/2020 OPW 104-635 Ex 3- 14-2020 <br /> Emco 3205 Ex . 11 / 16/2020 ATG : VR A31048 Ex . 8/9/ 19 Incon 1009893708 11 /30/2020 <br /> 111: OVERFILL PREVENTION ' EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : remove and inspected <br /> Used : <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 4 <br /> TANK ID : (By tank number, stored product, etc.) 91 87 MASTER 87 SLAVE DIESEL <br /> What is the tank inside diameter? (inches) 96 96 96 96 <br /> Is the fill piping secondarily contained ? ❑ Yes x❑ No ❑ Yes [E No ❑ Yes R No ❑ Yes 0 No <br /> Is the vent piping secondarily contained? ❑ Yes 0 No ❑ Yes ❑x No ❑ Yes F1 No ❑ Yes x❑ No <br /> Overfill Prevention Equipment Manufacturer(s ) OPW OPW OPW OPW <br /> 61 SO 61 SO 61 SO 61 SO <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow N Shuts Off Flow 91 Shuts Off Flow Z Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) El Restricts Flow El Restricts Flow ❑ Restricts Flow El Restricts Flow <br /> ❑ AIV Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping? ❑ Yes 2 No ❑ Yes R No ❑ Yes E No ❑ Yes Q No <br /> At what level in the tank is the overfill prevention set 85 $ 0 . 00 80 . 00 80 . 00 <br /> to activate . (Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which the 97 93 93 93 <br /> overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating condition ❑x Yes Z Yes ❑x Yes Z Yes <br /> to respond when the substance reaches the <br /> El level? No (Specify in V.) El No (Specify in V.) El No (Specify in V.) [:1 No (Specify in V.) <br /> It <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑ Pass ❑x Fail 9 Pass ❑ Fail ❑Q Pass ❑ Fail Z Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" must be explained in this section . Any additional comments may also be provided here. <br /> 91 DROP TUBE FLAPPER SET TO HIGH . <br /> Vi . CERTIMA71ON BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> 1 hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations , Title 23, <br /> Division 3 , Chapter 16 , Section 2637 , 2 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 = kient kationl UST = Underground Storage Tar>Ec, ICC = International Code Council, AA1 = Audible and Vsual <br />