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UNDERGROUNDSTORAGETANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page 1 of 1) <br /> Type of Action F Installation Test Repair Test � 36 Month Test <br /> F <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection: <br /> 10184563 2/21/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Chevron 212470 <br /> Business Site Address City: Zip: <br /> 3400 N MacArthur Drive Tracy 95376 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> Jesus Saldivar (800)800-4633 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Class A General Engineering 743160 8361393 6/16/2019 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> Veeder Root-VR Level 4 845334 05/01/2019 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Manufacturer Guidelines (Specify) <br /> Test Method Used: F1-0-Industry Code or Engineering Standard (Specify) PEI RP 1200 <br /> r Engineered Method S ecif <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.) 91 87 dsl <br /> What Is the tank inside diameter?(Inches) 117.75 in. 117.75 in. 118.13 in. <br /> Is the fill piping secondarily contained? r Yes r No W Yes r No Yes r No r Yes r No <br /> Is the vent piping secondarily contained? r Yes P No r Yes r No r Yes P No r Yes r No <br /> Overfill Prevention Equipment Manufacturer(s) <br /> other other other <br /> What is the overfill prevention equipment response r Shuts Off Flow r Shuts Off Flow Shuts Off Flow (-Shuts Off Flow <br /> when activated?(Check all that apply.) r Restrict Flow r Restrict Flow I—Restrict Flow r Restrict Flow <br /> Fv-AN Alarm AIV Alarm Fv-1 AA1 Alarm f AN Alarm <br /> Are flow restrictors installed on vent piping? r/ Yes r No 570 Yes r No Pr Yes r No r Yes r No <br /> At what level in the tank is the overfill prevention set to <br /> activate?(inches from bottom of tank.) 97 98 9g <br /> What is the percent capacity of the tank at which the 90 90 90 <br /> overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating condition Yes P Yes r Yes r Yes <br /> to respond when the substance reaches the r No r No r No r No <br /> appropriate level? <br /> Spesify in section V) ISpesify in section V) Spesify in section V) (Spesify In section V) <br /> N. SUMMARY OF TESTING RESULTS <br /> Overfill Prevention Inspection Results Pass r Fail s 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 /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations,title 23,division 3,chapter 16,section <br /> 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 />