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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM <br /> Type of Action ❑ Installation Inspection ❑ Repair inspection I'M.► 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Dale of Overfill Prevention Equipment Inspection <br /> q 161435 5/29/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> KETTLEMAN CHEVRON <br /> Business Site Address T City ZIP Cade <br /> 601 E KETTLEMAN LANE _ LODI 95240 <br /> ll . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Parforming the Inspection (Print as shown Qn the ICC Certification) Phone # <br /> David Winkler _ (209 ) 744- 0112 <br /> Contractor t Tank Tester License #k ICC Certification #? ICC Certification Expiration Date <br /> 08- 1739 Ex. 3131 /2020 8883059-UT 1 /29/2020 <br /> Overfill NreveniloiiEquipment Inspectlon Tralning and certlncatlons (List applicable certifications.) <br /> FFry EBW , Phil-Tice & EVR Phase 1 1009853708 Ex 11 /29/20 OPW 104- 833 Ex 3" 14-2024 <br /> Emco 93207 Ex . 11 / 16/20 ATG : VR : B34975 ATG ; 218/20 INCOIN 1009803708 Ex , 11 /30/2020 <br /> ill . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method 0 Manufacturer Guidelines (Specify) : <br /> used : REMOVED PROBES AND BALL FLOATS <br /> C] Industry Code or Fngineering Standard (Specify): r <br /> ❑ Englnaerod Mathod (Speclfy)& <br /> Attach the inspection procedures and an documentation required to determine the results. Xt of Attacliad Pegas <br /> TANK ID: (By tank number, stored product, etc.) 871 87 2 91DSL <br /> What is the tank inside diameter? (inches) 9575 95v75 89 . 75 , . 95075 <br /> Is the till piping secondarily contained? ❑x Yes L] No Rl Yes ❑ No ❑ Yes p No Q Yes Q No <br /> Is the vent piping secondarily contained? ❑ Yes I] No ❑ Yes QNo ❑ Yes x© No Q Yea 91 No <br /> Overfill Prevention Equipment Manufacturer(s) VR VR Viz VR <br /> PROSE PROBE PROBE PROBE <br /> What is the overfill prevention equipment response Shuts Of Flow ❑ Shuts OfFlow Shule Off Flow dShuts off Fle_w ,... <br /> When eotivated? <br /> (Chock all thst apply") ❑ Restricts Flaw ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ® AN Alarm 9 AN Alarm x❑ AN Atami �Jx AN Alann <br /> Are flow restrictors installed on vent piping? I] Yes ❑ No ❑x Yes ❑ No x❑ Yes ❑ No Yes El No <br /> At what level in the tank 15 the overfill proventlon set <br /> to activate? ftnchas from bottom of tank.) 80 , 87 30 . 87 75 80 . 75 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90 90 90 90 <br /> In the overfill prevention in proper operating conditionxU' Yes Yes F21 Yes Yes <br /> to respond when the substance reaches the <br /> appropriate levet? [] No (Specify in V) ❑ No ($pacify in tr ) ❑ No (Specify in V,) ❑ No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results m Pass 0 Fail I]x Pass ❑ Fail Q Pass Q Fall 5fl f'Bss © Fdll <br /> Ve COMMENTS <br /> Any !terms marked Fail" trust be explained In this section . Any additional comments may also be, provided hare, <br /> ALSO TESTED BALL FLOATS ALL PASS <br /> k%000 <br /> VI . CERTIFICATION BY UST 5 RViI? HNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was Inspi ted In accordance with California Cade of Regulations, Tlftlo'430 <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 cop/es of this page may be etMchedr <br /> CERS T California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Inttnatlonal C(xle Coundl, AN Audible and Visual <br />