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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action Installation inspection -. _ ❑Repair Inspection ©36 Month inspection CER10 1. FACILITY INFORMATION -- S �- 10184563 Date of Overfill Prevention Equipment Inspection Business Name(Same as Facility Name or DBA-Doing Business As) _ - __ 10/5/18 Chevmn 212470 Business Site Address 3400 N MacArthur i1P Code - _ Trac _ ON _ i 95376 _ II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATI Name of UST Service Technician Performing the Inspection(print as shown on the ICC Cerbacabon) Phone a Edwin Pineda (209)365. 46 Ern 74311 ctorrTank Tester License* ICC Certification t 1 ICC Certification Expiration Date --� 743160 8373052 ; 6/26/19 Eq Overfill Prevention Equipment Inspection Training and CerSficationa(List appkcable certiacabons) — -- - . OPW 100726 1L].6/19 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORM_ATION inspection Method Used.- ®Manufacturer Guidelines(Specify)OPW — ❑Industry Code or Engineering Standard(Spec fy) ❑Engineered Method(Spec;tyi Athch the kispecdwprocedures and ad documentation required to determine the results. III of Attached Pages Tank ID (By tank number stored product etc) T1 Prem_ __ T2 R T3 DI@SAI ` What is the tank Inside diameter?(Inches) - - - Is the fill piping secondarily contained ®11 Yes ❑No 0 Yes ❑No ❑Yes ❑No El Yes ❑No Is the vent piping secondarily contained? ❑Yes ®No ❑Yes 0 No ❑Yes _ _ _ ®No ❑Yes ❑No Overfill Prevention Equipment Manufachxer(s) OPW OPW OPW What is the overfill prevention equipment ❑Shuts Ott Flow ❑Shuts Oft Flow ❑Shuts Off Flow ❑Shuts Ott Flow response when activated? ®Restricts Flow ®Restricts Flow ®Restricts Flow ❑Restricts Flow (Check all that apply) ❑AIV Alarm ❑AN Alarm ❑A(V Alarm ❑AIV Alarm Are How restnctors installed on vent pipings ®Yes ❑No ®Yes ❑No ®Yea ❑No _ ❑Yes ❑No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank) 105 105 106 What is the percent capacity of the tank at which - -- — _ the overfill prevention equipment acbvates> 95 95 95 Is the overfill prevention in proper operating =Yes ®Yes ®Yes ❑Yes condition to respond when the substance teaches the appropriate level? ❑No ❑No ❑No (Specify in section V li fSPe m eeef:on v ` Y ) (3p.—fy In acuwoo V) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results _ ®Pass ❑Fail Pass ❑Fail Q Pass Fail ❑ ❑FaH V. COMMENTS 4ll items marked'Fatt-must be enolained to this section Any additional comments may also be provided here Site has both an external alarm and ball floats VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations,title 23,division 3, chapter 16,section 2637.2 and all the information contained herein is accurate. UST Service Technician Signature - - - --- - -- { N the faeiNty has more components than this form accommodates, additional copies of-this-page may be attached. CERS=GaRoniia EnViOnimental RefxwWirl Systuir IC,=kksrtficroon.UST=Unrfcv At"A storage talk.ICC=k4erru0anal Code Council.AN=PAidibie and visual