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w s <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Inspection ❑Repair Inspection ®36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181329 13-10-19 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> MANTECA CHEVRON <br /> Business Site Address City ZIP Code <br /> 1257 W. YOSEMITE MANTECA CA <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 /> MARK WILLIAMS 559 688-2977 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> A304137 8198890 9-27-19 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: ❑Manufacturer Guidelines(Specify) <br /> ® Industry Code or Engineering Standard(Specify)PFI 1200 <br /> ❑ Engineered Method(Specify) <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages: <br /> Tank ID: (By tank number,stored product, etc.) 91 87 DIESEL <br /> What is the tank inside diameter?(Inches) 92 92 92 <br /> • Is the vent piping secondarily containe ?DPwes•❑ Noe® Y sn�Oo•®Yes-❑ ,Gq3*s•❑ Noe• Ov rfill Prevention Equipment <br /> Overfill Prevention Equipment Manufacturer(s) <br /> What is the overfill prevention equipment ® Shuts Off Flow rEjRestricts <br /> s Off Flow ®Shuts Off Flow E]Shuts Off Flow <br /> response when activated? El Restricts Flow Flow ❑Restricts Flow ❑Restricts Flow <br /> (Check all that apply.) ❑AN Alarm ❑A/V Alarm ❑AN Alarm ❑AN Alarm <br /> At what I&6imAteti IemkAntttwdaeifilb0hoem0 ff I p evention sg4o activate?(Inches fro�sottom of t k.)•$3•;$3. 839 • •What is the <br /> set to activate?(Inches from bottom of tank.) t5.) o <br /> What is the percent capacity of the tank at which 95 95 95 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating ®Yes M Yes ®Yes ❑Yes <br /> condition to respond when the substance ❑ No ❑ No ❑ No ❑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 INSPECTION RESULTS <br /> V. COMMENTS <br /> All items marked"Fail'must be explained in this section. Any additional comments may also be provided here. <br /> :WR 2 4 201 <br /> '\:\ <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCl'ING <br /> I hereby certify that the overfill prevention equipment was Inspected in accordance with California Code of Regulations,title 23,division 3, <br /> chapter 16,section 2637.2 and all the information contained herein is accurate. <br /> UST Service T ian IS', nature <br /> If the facility h s ore c mponents an_ s form accom dates,additional copies of this page maybe attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council,AN=Audible and visual <br />