Laserfiche WebLink
t <br /> iiiiiiiiiiiiiiiiiiii NINE Ill 1111111 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test Repair Test r 36 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection : <br /> 10184539 12/6/2018 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> CHEVRON 210997 ( N-4693) <br /> Business Site Address City: Zip : <br /> 1442A COLONY DR, RIPON 95366 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test ( Print as shown on the ICC Certification . ) Phone # <br /> TANKNOLOGY INC. (800) 800-4633 <br /> �7 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8211862 6/23/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> CA - Tightness Testing 14- 1759 06/30/2020 ICC - CA UST Service Technician 8211862 06/23/2019 <br /> Ill. SPILL CONTAINER TESTING INFORMATION <br /> Manufacturer Guidelines (Specify) <br /> Test Method Used : r Industry Code or Engineering Standard (Specify) PEI RP 1200 <br /> F 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.) T1 : SUPREME T2 : REGULAR <br /> UNLEADED UNLEADED <br /> What is the tank inside diameter? ( Inches) 117 . 75 in . 117 . 75 in. <br /> Is the fill piping secondarily contained ? rYes r No rYes [ No [ Yes [ No [ Yes [ No <br /> Is the vent piping secondarily contained ? rYes r No [ Yes r No rYes [ No [ Yes [ No <br /> Unknown Unknown <br /> Overfill Prevention Equipment Manufacturer(s) <br /> OPW OPW <br /> What is the overfill prevention equipment r Shuts Off Flow r Shuts Off Flow r Shuts Off Flow r Shuts Off Flow <br /> response when activated ? [ Restrict Flow [ Restrict Flow r Restrict Flow r Restrict Flow <br /> (Check all that apply . ) r A/V Alarm r A/V Alarm r A/V Alarm r A/V Alarm <br /> Are flow restrictors installed on vent piping ? I Yes [ No [ Yes [ No rYes [ No rYes [ No <br /> At what level in the tank is the overfill prevention 98 . 75 105 . 375 <br /> set to activate? ( Inches from bottom of tank. ) <br /> What is the percent capacity of the tank at which 90 95 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating r Yes r Yes [ Yes r Yes <br /> condition to respond when the substance r No r No r No r 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 TESTING RESULTS <br /> Overfill Prevention Inspection Results r Pass r Fail r' Pass r Fail r Pass [ Fail [ 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 /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 23, division 3 , chapter 16, <br /> section 2637 . 1 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=Identification , UST= Underground storage tank, ICC=International Code Council <br />