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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 M 36 Month Inspection <br /> I.FACILITY INFORMATION <br /> CERS ID 10443520 Date of Overfill Prevention Equipment Inspection <br /> 9/26/18 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> THORNTON CHEVRON <br /> Business Site Address City ZIP Code <br /> 9015 WALNUT GROVE THORNTON,CA 95351 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Pent as shown on the ICC Certification.) Phone# <br /> DAVE WINKLER 209 744 -0112 Ext. <br /> ContractorlTank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 8883059-UT 1-31-20 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW,Phjj-Tite <br /> ertcations.) <br /> -Tie &LYR Phase 1 1009853708 'x 11-1 -1 W 104-633 -14- 2 #3207 Ex.09-21-2020 VR:B 4 75 ATG,2 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: M Manufacturer Guidelines(SpecWEDER ROOT REMOVED PROBES <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: <br /> Tank ID:(By tank number,stored product,etc.) 87 91 DSL <br /> What is the tank inside diameter?(Inches) 119.60 119.60 119.60 <br /> Is the fill piping secondarily contained? M Yes ❑ No M Yes ❑No M Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? M Yes ❑ No M Yes ❑No M Yes ❑No ❑Yes ❑No <br /> VEEDER ROOT VEEDER ROOT VEEDER ROOT VEEDER ROOT <br /> Overfill Prevention Equipment Manufacturer(s) <br /> PROBE PROBE PROBE <br /> What is the overfill prevention equipment ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> response when activated? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) M AN Alarm M AN Alarm ®AN Alarm ❑AN Alarm <br /> Are Flow restrictors installed on vent piping? ❑Yes M No ❑Yes M No ❑Yes M No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention107 107 <br /> set to activate?(Inches from bottom of tank.) 107 <br /> What is the percent capacity of the tank at which 90 90 90 <br /> the overall prevention equipment activates? <br /> Is the overfill prevention in proper operating M Yes M Yes Was ❑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 /> Overfill Prevention Inspection Results ® Pass ❑ Fail I M Pass ❑Fail I M Pass ❑ Fail ❑Pass ❑ Fail <br /> V. COMMENTS <br /> Ali items marked"Fail'must be explained in this section. Any additional comments may also be provided hem. <br /> nr-n n lcn <br /> v <br /> V L. Lof <br /> 6 <br /> ENVIRONMENTAL HEALTH <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <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 Technician Signature vl ] <br /> ff 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,AIV=Audible and visual <br />