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UNDERGROUND GE TANK OVERFILL PREVENTION EQUIPMENT NSPECT ON REPORT FORM (Page 1 of 1) Type of Action ❑InstaitationYtspeciton ❑Repair Inspection ®36 Month Inspection CERS ID I. FACILITY-INFORMATION --- -- - _ - - -- - __ ---- —. 10184563 Date of OvefiU Pd I revention Equipmernspection Business me(Satre as Faodrry Name or DBA-Doing Business As; 10/5/18 Chevron212470 _ Business Site Addrote -- -- - -- 3400 N MacArthur City zip code - ' -- Trac tom_ - 95376 II. UNDERGROUND STORAGE_ s cattor?TANK SERVICE TECHNICIAN INFO N Name of UST Serviee Technician Performing the Inspection(Print as shown on the/cc certibPhone Edwin Pineda (209) 65- 1246 ContractorrTank Tester Licenses ICC Certlfiestion! ICC Certification Expiration Date 743160 _ 8373052_ _j 6/26/19 Overfill Prevention E -_— qupment Inspection Training and Certifications(List applicable oerbficatrons Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used. ®Manufacturer Guidelines(Specifo OPW ❑Industry Code or Engineering Standard(Specify) I ❑Engineered Method(Specify) Af�aeh the dns ------------- pecdoo procedures and all documentation raquked to determine Ehe results. sof Attached Pages It TT"ID (By(ank number. stored product.etc) T1_Prem T2 — T3 Diesel I What is the tank inside diametd7(tushes) --is the fill Aping secondarily contained? ®Yes ❑No ®Yes ❑No ❑Yes - ❑No ❑Yes ❑No Is the vent piping sieconderity contained? ❑Yes ®No ❑Yes ®No - ❑Yes ®No ❑Yes ❑No Overfill Prevention Equipmerd Manufacturer(s) OPw _ oPw What is the overfill prevention equipment ❑Shuts OH Flow $hofs Off Flow ❑Shama af<Alpo ❑Shuts Off Flow response when activated? Q Restricts Flow ®Restricts Flow (Check all that apply) ®Restricts Flow El Restricts Flow ❑AN Alarm ❑AN Alarm ❑AN Alarm ❑AN Alarm Are flow restrictors installed on vent v ——- PlPirr9 ®Yes -— ❑No ®Ysa ❑No �Yes ❑No ❑Yes ❑No At what level in the tank is the overfill prevention — - —- �set to activate?(inches from bottom of tank) 105 1055' 106 What is the percent capacity of the tank at which -the overfill prevention equipment acbvetes*? 95 95 95 Is the overfill prevention in proper operating--- ®Yes Yes 0 Yes ❑Yes -- - condition to respond when the substance ❑No reaches the appropriate levet? ❑No ❑No ❑No (SprKYfy in section V) (Specify in section V 1 (Specify in eedion V) (spc jfy nxouun V) N. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ®Pass [I Fail 0 Pass ❑Fail ®Pass ❑Fail ❑p ❑Fail V. _COMMENTS Olt items marked'Fail-must be explained rn this section Any additional comments may also be prov ded h Site has both an external alarm and ball floats VI, VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING TO* �F H - - --- hereby certify all the overfill prevention equipment was inspected in accordance with California Code of Regulations,title 23,division 3, chapter is,section 26772 and all the information contained herein is accurate. UST Service Technician Signature -- M the(aciltty has mon conrporrants than this form accommodates,ad—di—do-nal copies of this page(nay be attached. -- ----- CERS a Cabornia ErNkorsnee Reporloig Syswm D a bwfl,_6on,UST a Undwgmutd storage iii,ICC_&iwnatkx Code Cenci Am=Aulibi a and venal s "