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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection is 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10180519 8/28/19 Business Name (Same as Facility Name or DBA-Doing Business As) Shell #68150 Business Site Address City ZIP Code 13975 E Hwy 88 Lockeford 95237 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the JCC Certification.) I Phone # Brian McPheely (408) 971 -2445 Contractor I Tank Tester License # F88�22062 C Certification # ICC Certfcation Expiration Date 485184 111 / 19/19 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) B36745 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method V1 Manufacturer Guidelines (Specify): Used : Veeder Root ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) I -Reg 2-Prem 3-DSL What is the tank inside diameter? (Inches) 120 120 120 Is the fill piping secondarily contained ? p Yes ❑ No W1 Yes ❑ No [0 Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ® Yes ❑ No 10 Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) Veeder Root Veeder Root Veeder Root What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated? (Check all that apply.) ElRestricts Flow ElRestricts Flow ❑ Restricts Flow ElRestricts Flow m AN Alarm IZI AN Alarm m AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping ? ❑ Yes © No ❑ Yes © No ❑ Yes [Z No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (inches from bottom of tank.) 107 .875 107 .375 108 .625 What is the percent capacity of the tank at which the o 90% 90% overfill prevention equipment activates? 90% Is the overfill prevention in proper operating condition O Yes ® Yes la Yes ❑ Yes to respond when the substance reaches the E appropriate level? ❑ No (Specify in V) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results 0 Pass ElFail 0 Pass ❑ Fail OF ass ❑ Fail El Pass ❑ Fail _ V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. Vi . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations, Title 233 Division 3, Chapter 16, Section 2637. 2 and all the Information contained herein is accurate. UST Service Technician Signature ff the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, AN Audible and Visual r I I