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UNDERGROUNDSTORAGETANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page 1 of 1) <br /> Type of Action F,/ Installation Test I— Repair Test r 36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID 76/5/200f20 <br /> e Overfill Prevention Equipment Inspection: <br /> 10182313 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> CHEVRON#208117 <br /> Business Site Address City: Zip: <br /> 755 S.TRACY BLVD TRACY 95376 <br /> It. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> Clint Fuhrman (800)800-4633 <br /> ContractorfTank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Class A General Engineering 743160 9160945 5/2/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Ir Manufacturer Guidelines(Specify) OPW <br /> Test Method Used: r 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.) T2 <br /> What is the tank inside diameter? (Inches) 117.75 in. <br /> Is the fill piping secondarily contained? r Yes r No r Yes r No r Yes r No r Yes r No <br /> Is the vent piping secondarily contained? W Yes r No r Yes r No r Yes r No r Yes r No <br /> Unknown <br /> Overfill Prevention Equipment Manufacturer(s) <br /> OPW <br /> Shuts Off Flow r Shuts Off Flow r Shuts Off Flow r Shuts Off Flow <br /> when act <br /> What cthe overfill prevention equipment response r Restrict Flow Restrict Flow r Restrict Flow r Restrict Flow <br /> activated?(Check all that apply.) r A/V Alarm (—AA/Alarm A/V Alarm r A/V Alarm <br /> Are flow restrictors installed on vent piping? r—Yes r No r Yes r No r Yes r No r Yes r No <br /> At what level in the tank is the overfill prevention set to 105 <br /> activate?(Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which the 95 <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 I— No r No r No <br /> appropriate level? in section V (Specify ) (Specify ) (Specify' ) <br /> (Specify' ) (Speci in section Vin section Vin section V <br /> IV. SUMMARY OF TESTING RESULTS <br /> Overfill Prevention Inspection Results W Pass r Fail r Pass r Fail r Pass r Fail I 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 /> Removed and replaced old drop tube due to cut being more than 6"from the bottom of tank <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> 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 /> 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 />