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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM <br /> Type of Action: ❑Installation Inspection ❑Repair Inspection ®36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment <br /> I spection 12/27/2018 <br /> Business Name Chevron <br /> Business Site Address 2758 W Kettleman City Lodi Zip Code <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Service Technician(on ICC Certification) Tim Burkart I <br /> Phone# 916-371-2380 <br /> Contractor License#: 433159 ICC Certification: 00210960 ICC Expiration Date: <br /> Overfill Prevention Equipment Relevant Certifications(List Applicable): <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑Manufacturer Guidelines(Specify): <br /> Used: <br /> ®Industry Code or Engineering Standard(Specify): PEI 1200 <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of attached pages: <br /> Tank ID:(By tank number,stored 87 91 D L <br /> What is the tank inside diameter?(inches) 119.50 <br /> Is the Fill Piping Secondarily contained? ®Yes ❑No ®Yes ❑No EEO Yes ❑No ❑Yes ❑No <br /> Is the Vent Piping Secondarily contained? ®Yes ❑No ®Yes ❑No El Yes ❑No <br /> E]Yes ❑No <br /> Overfill Prevention Equipment Emco Emco Emco <br /> Manufacturer <br /> Tank Manufacturer <br /> What is the overfill prevention equipment ®Shuts Off Flow ®Shuts Off Flow Shuts Off Flow ❑Shuts Off Flow <br /> response when activated? ❑Restricts Flow ❑Restricts Flow Restricts Flow <br /> ❑Restricts Flow <br /> (Check all that apply) ❑A/V Alarm ❑A/V Alarm A/V Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent ❑Yes 9No ❑Yes ®No Yes ®No ❑Yes ❑No <br /> piping? <br /> At what level in the tank is the overfill <br /> prevention set to activate?(Inches from 102" 101" 103" <br /> bottom of tank.) <br /> What is the percent capacity of the tank at <br /> which the overfill prevention equipment 92 94 94 <br /> activates? <br /> Is the overfill prevention in proper ®Yes ®Yes 21 Yes ❑Yes <br /> operating condition to respond when the ❑No(Specify in V.) ❑No(Specify in V.) No(Specify in V.) ❑No(Specify in V.) <br /> substance reaches the appropriate level? <br /> IV. SUMMARY OF INSPECTION RESULT <br /> Overfill Prevention Inspection Results ®Pass ❑Fail I ®Pass ❑Fail Pass ❑Fail ❑Pass ❑Fail <br /> V. COMMENTS <br /> Any items marked"Fail"must be explained in this section.Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations,Title 23, <br /> Division 3,Chapter 16,Section 2637.2 and all the information contained herein Is accurate <br /> UST Service Technician Signature __ <br />