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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑x Installation Inspection ❑ Repair Inspection ❑ 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 7/1/2022 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Shell <br /> Business Site Address City ZIP Code <br /> 2375 W Grant Line Rd Tracy 95377 <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 /> Raul Ortega (760) 722-9002 <br /> Contractor/Tank Tester License# ICC Certification# Certification Expiration Date <br /> ICC <br /> 888681 8468846 6/21/2024 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FFS EVR <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑Manufacturer Guidelines(Specify): <br /> Used: <br /> x❑ 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 1 <br /> TANK ID: (By tank number,stored product,etc.) 87 87AuX 91 Diesel <br /> What is the tank inside diameter?(Inches) <br /> Is the fill piping secondarily contained? ❑x Yes ❑ No x❑Yes ❑ No ❑x Yes ❑No ❑x Yes ❑ No <br /> Is the vent piping secondarily contained? ❑x Yes ❑No ❑x Yes ❑ No ❑x Yes ❑No ❑x Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) FF Defender FF Defender FF Defender FF Denfender <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow N Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑ Restricts Flow ❑Restricts Flow E Restricts Flow E Restricts Flow <br /> ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes 0 No E Yes 0 No E Yes 0 No E Yes E No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 78.25 77.50 77 77.50 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 92% 92 0 92% 92% <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑x Yes ❑x Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑ No(Specify in V.) E No(Specify in V.) E No(Specify in V.) E No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ❑ Fail ❑x Pass E Fail ❑x Pass E Fail E Pass E 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 N 0 <br /> If the facility has more components than this form accomrhodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AA/=Audible and Visual <br />