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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Pagel of 1 ) <br /> Typeof Action El Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181343 9/ 19/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> West Lane Chevron <br /> Business Site Address City ZIP Code <br /> 4747 West Lane Stockton 95210 <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 /> Zane Nimmo ( 209 ) 744 - 0112 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 04- 1676 Ex . 03/31 /2019 8883064-UT 6/ 1 /2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- EBW , Phil-Tite & EVR Phase 1 10009843708 Ex 11 - 16- 18 OPW 104-632 Ex 3- 14-2020 <br /> Emco 3206 Ex , 9/21 /2020 VR : A28446 ATG : 9/28/ 19 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : <br /> Used : O P W <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, storedproduct, etc.) 1 - 87 East 2 - 87 Middle 3 - 91 OCT <br /> What is the tank inside diameter? (Inches) 92 92 92 <br /> Is the fill piping secondarily contained ? Z Yes ❑ No x❑ Yes ❑ No E Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑x Yes ❑ No ❑x Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) oPW oPW oPW <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ❑ A/V Alarm ❑ AIV Alarm ❑ AIV Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes 0 No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 82 80 82 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 94 93 94 <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑x Yes EJ 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 ❑x Pass ❑ Fail 9 Pass ❑ Fail ❑x Pass ❑ Fail ❑ 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 /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipmentwas 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 = Car6omia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Usual <br />