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�aNVIlIQ <br />If the facility has more components n this form aZnrumrriodht'es, additional copies of rms page maybe arracneo. <br />CERS = California Environmental Reportlng tem, ID =Identification, UST =Underground Storage Tank, ICC = International Code Council, AN =Audible and <br />UNDERGROUND STORAGE TANK <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />A <br />f i= ❑ Installation Inspection El Repair Inspection ®36 Month Inspection <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Overfill Prevention Equipment Inspection <br />10411900 <br />10/8/18 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Tesoro Shell 68221 <br />Business Site Address <br />City <br />ZIP Code <br />2705 Country Club Blvd <br />Stockton <br />95204 <br />11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) <br />Phone # <br />Michael Briggs <br />(408) 971-0135 <br />Contractor I Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />128811 <br />8033115 <br />5/30/19 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />OPW Certification <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />® Manufacturer Guidelines (Specify): OPW 71 SO Overfill Prevention Valves and Installation & Maint Instructions <br />Used: <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the inspection procedures and all documentation required to determine the results. <br /># of Attached Pages 25 <br />TANK ID: (By tank number, stored product, etc.) 87 <br />91 Diesel <br />What is the tank inside diameter? (Inches) <br />Is the fill piping secondarily contained? 0 Yes ❑ No <br />I] Yes ❑ No ❑✓ Yes ❑ No ❑ Yes ❑ No <br />Is the vent piping secondarily contained? ® Yes ❑ No <br />© Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No <br />Overfill Prevention Equipment Manufacturer(s) OPW <br />OPW OPW <br />What is the overfill prevention equipment response ❑ Shuts Off Flow <br />❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br />when activated? <br />®Restricts Flow <br />®Restricts Flow ®Restricts Flow El Restricts Flow <br />(Check all that apply.) <br />❑ A/V Alarm <br />❑ AIV Alarm ❑ A/V Alarm ❑ AIV Alarm <br />Are flow restrictors installed on vent piping? ❑ Yes ❑✓ No <br />❑ Yes ❑✓ No ❑ Yes ® No ❑ Yes ❑ No <br />At what level in the tank is the overfill prevention set <br />94.4 96.7 <br />to activate? (Inches from bottom of tank.) <br />What is the percent capacity of the tank at which the <br />94.4 96.7 <br />overfill prevention equipment activates? <br />Is the overfill prevention in proper operating condition ❑ Yes <br />® Yes ❑ Yes ❑ Yes <br />to respond when the substance reaches the <br />❑ No (Specify in V.) <br />❑ No (Specify in V) ® No (Specify in V) ❑ No (Specify in V.) <br />appropriate level? <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results ❑ Pass ® Fail <br />10 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 />Unable to remove 87 bucket to access drop tube to get measurements. 91 passed, and Diesel failed at 96.7% <br />Rtr ^ <br />'it <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSM <br />qT19y <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 ENVIRONIVIEN I ALFlEA1 TIF <br />,� to 2(R'M E N <br />Visual <br />