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UNDERGROUNDSTORAGETANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Pagel 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 /> 10181337 9/7/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> CDR Tracy Chevron <br /> Business Site Address City ZIP Code <br /> 3775 Tracy Blvd Tracy 95376 <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 /> David Winkler 1 (209) 744-0112 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 Ex.3/31/2020 8883059-UT 1/29/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW, Phil-Tite &EVR Phase 1 1009853708 Ex 11-16-18 OPW 104-633 Ex 3-14-2020 <br /> Emco #3207 Ex. 09-21-2020 VR: B34975 ATG: 2/8/20 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑Manufacturer Guidelines(Specify): <br /> Used: VR - Probe <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 3 <br /> TANK ID:(By tank number,stored product,etc.) 87 91 D S L <br /> What is the tank inside diameter?(Inches) 117.75 117.75 117.75 <br /> Is the fill piping secondarily contained? ❑x Yes ❑No 0 Yes ❑No 0 Yes ❑ No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? ❑Yes [E No ❑Yes I]No ❑Yes E] No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) VR VR VR <br /> PROBE PROBE PROBE <br /> What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) ❑ <br /> Restricts Flow Restricts Flow El Restricts Flow EI Restricts Flow <br /> ❑x AN Alarm 0 AN Alarm ❑x AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? El Yes ❑No E Yes ❑No Z Yes ❑No ❑Yes [:]No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 98 98 98 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90 90 90 <br /> Is the overfill prevention in proper operating condition ❑x Yes Q Yes 0 Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No(Specify in V) ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results Z Pass El=Fail Pass ❑Fail ❑x Pass ❑Fail-11 ❑ 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 /> Ball floats installed and operational <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, <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 maybe attached. <br /> CERS=Cardbmia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AN=Audible and Visual <br />