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F <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page ',1 of 1 ) <br /> Type of Action Installation Test Repair Test 36 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection : <br /> 10/2/2018 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> Chevron 372736 <br /> Business Site Address City: Zip: <br /> 9484 West Lane Stockton 95210 <br /> Ill. 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 /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8373052 6/26/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> ICC - CA UST Service Technician 8373052 06/26/2019 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Manufacturer Guidelines (Specify) OPW <br /> Test Method Used : Wi 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.) 40 <br /> What is the tank inside diameter? ( Inches ) 92 . 00 in . <br /> Is the fill piping secondarily contained ? rYes [ No rYes r No rYes r No rYes r No <br /> Is the vent piping secondarily contained? rYes r' No rYes r No rYes [ No rYes r No <br /> Unknown <br /> Overfill Prevention Equipment Manufacturer(s) <br /> OPW <br /> What is the overfill prevention equipment Shuts Off Flow r Shuts Off Flow [ Shuts Off Flow 7% Shuts Off Flow <br /> response when activated ? [ Restrict Flow [ Restrict Flow [ Restrict Flow [ Restrict Flow <br /> (Check all that apply. ) r A/V Alarm [ A/V Alarm [ A/V Alarm r A/V Alarm <br /> Are flow restrictors installed on vent piping ? rYes IV' No rYes r No rYes r No [ Yes [ No <br /> At what level in the tank is the overfill prevention 81 . 125 <br /> set to activate? ( Inches from bottom of tank. ) <br /> What is the percent capacity of the tank at which o <br /> the overfill prevention equipment activates? 95 /o <br /> Is the overfill prevention in proper operating W Yes r Yes [ Yes [ Yes <br /> condition to respond when the substance r No r No r No r No <br /> reaches the appropriate level? (Specify n section V (Specify n section V <br /> (Sp fyi ) S( p fyi ) (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 r Fail 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 /> 87 and 91 tubes seized . Will return for inspection . Measured in place on this visit. <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, <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, IGC=International Code Council <br />