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GEIVED <br /> UNDERGROUND STORAGE TANK <br /> 0 C T 16 OARFILL'PREVENTION (EQUIPMENT INSPECTION REPORT FORM(Page i of I) <br /> Type of Action ❑Installation Inspection ❑Repair Inspection ®36 Month Inspection <br /> EN VIRONMEN I AL HEALTH 1. FACILITY INFORMATION <br /> CE Date of Overfill Prevention Equipment Inspection <br /> 1 1229 110/10/18 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Tesoro Shell 68151 <br /> Business Site Address City ZIP Code <br /> 35 N Cherokee Ln Lodi 95240 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Michael Briggs 1(408)971-0135 <br /> Contractor/Tank Tester License# BCC Certification# ICC Certification Expiration Date <br /> 128811 8033115 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 ®Manufacturer Guidelines(Specify): <br /> Used: OPW 61 SO&71 SO Overfill Prevention Valves and Installation Instructions <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages 32 <br /> TANK ID:(By tank number,stored product,etc.) 87 91 Diesel <br /> What is the tank inside diameter?(Inches) 95.5 95.5 95.5 <br /> Is the fill piping secondarily contained? ❑Yes ®No ❑Yes ❑No ❑Yes ®No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes ®No ❑Yes ❑No ❑Yes ®No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) OPW 61 SO OPW 71 SO <br /> What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ®Restricts Flow ®Restricts Flow ®Restricts Flow ❑Restricts Flow <br /> ❑AN Alarm ❑A/V Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ®No ❑Yes ❑No ❑Yes ®No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 84 84 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 93.2 93.1 <br /> Is the overfill prevention in proper operating condition ®Yes ❑Yes ®Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ®Pass ❑Fail I ❑PassO 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 /> 91 has stuck nipple, could to remove. Unable to complete inspection on 91. 87 and Diesel passed <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> 1 hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations,Title 23, <br /> Division 3,Chapter 16,Section 263742 and all the information contained herein is accurate. <br /> UST Service Technician Signature '4W <br /> if the facility has more components ffiph this forma ,addltional copies of this page may be attached. <br /> CERS=California EmArtinmental Reporting Ayslem,ID= UST=Undergmund SWrage Tari-,ICC=International Code Council,AN=Audible and Visual <br />