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UNDERGROUNDSTORAGETANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page 1 of 1) <br /> Type of Action Installation Test Repair Test 36 Month Test <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 9 <br /> 376 <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 /> ContractorfTank 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 /> IIL OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Manufacturer Guidelines(Specify) <br /> Test Method Used: WO Industry Code or Engineering Standard (Specify) PEI RP 1200 <br /> F 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.) 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? iv Yes r No Yes r No Yes r No r Yes r No <br /> Is the vent piping secondarily contained? r Yes W No r Yes r No r Yes 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 r Shuts Off Flow r Shuts Off Flow <br /> when activated?(Check all that apply.) r Restrict Flow r Restrict Flow r Restrict Flow r Restrict Flow <br /> W1 AN N Alarm fO AAlarm AA/Alarm r AN Alarm <br /> Are flow restrictors installed on vent piping? 17 Yes r No P Yes r No R Yes r No r Yes r No <br /> At what level in the tank is the overfill prevention set to 97 98 99 <br /> activate. (Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90 90 90 <br /> Is the overfill prevention in proper operating condition r Yes r Yes r Yes r Yes <br /> to respond when the substance reaches the r No r No r No r No <br /> appropriate level? S esi <br /> p fY in section V) Spesify in section V) Spesify in section V) (Spesify in section V) <br /> N. SUMMARY OF TESTING RESULTS <br /> Overfill Prevention Inspection Results Pass r Failj R Pass r Fail P 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 <br /> REC,E V LE Dof <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS Hr,i <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations,title 23,division 3,chanter 16 section <br /> 2637.1 and all the information contained herein is accurate. "ENI- __ HEALtH <br /> UST Service Technician Signature/ DEPARTMENT <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br />