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UNDERGROUNDSTORAGETANK <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />rr rns7acurry nas more components than this form accommodates, additional copies of this page maybe attached. <br />-HERS = California Environmental Reporting System, ID = Identification, UST= Underground Storage Tank, ICC = International Code Council, AN= <br />Type of Action ❑ Installation Inspection ❑ Repair Inspection VI 36 Month Inspection <br />I. FACILITY INFORMATION <br />CERS ID <br />10181487 <br />Date of Overfill Prevention Equipment Inspection <br />9/25/18 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />Tesoro Shell 68153 <br />Business Site Address <br />2448 W Kettleman Ln <br />City <br />Lodi <br />ZiP Code <br />95242 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) <br />Michael Briggs <br />Phone # <br />(408) 971-0135 <br />Contractor / Tank Tester License # <br />128811 <br />ICC Certification # <br />8033115 <br />ICC Certification Expiration Date <br />5/30/ 9 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.). <br />OPW Certification <br />Ills OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMAT <br />Inspection Method <br />Used: <br />V1 Manufacturer Guidelines (Specify): OPW 71 SO Overfill Prevention Valves and Installation & Maint Instructions <br />❑ Industry Code or Engineering Standard (Specify): <br />DEPARTMENT <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.) <br />87 <br />91 <br />Diesel <br />What is the tank inside diameter? (Inches) <br />92" <br />92' <br />Is the fill piping secondarily contained? <br />❑ Yes ® No <br />❑ Yes ❑ No <br />❑ Yes © No <br />❑ Yes ❑ No <br />Is the vent piping secondarily contained? <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ® No <br />❑ Yes ❑ No <br />Overfill Prevention Equipment Manufacturer(s) <br />OPW 71SO <br />OPW 71 S0 <br />What is the overfill prevention equipment response <br />when activated? <br />(Check all that apply.) <br />❑ Shuts Off Flow <br />® Restricts Flow <br />❑ A/V Alarm <br />❑ shuts Off Flow <br />❑ Restricts Flow <br />❑ AIV Alarm <br />❑ Shuts Off Flow <br />® Restricts Flow <br />❑ A/V Alarm <br />❑Shuts Off Flow <br />❑ Restricts Flow <br />❑ A/V Alarm <br />Are flow restrictors installed on vent piping? <br />p Yes © No <br />❑ Yes ❑ No <br />El Yes ®No <br />EJ Yes ❑ No <br />At what level in the tank is the overfill prevention set <br />to activate? (Inches from bottom of tank.) <br />86 <br />89.5' <br />What is the percent capacity of the tank at which the <br />overfill prevention equipment activates? <br />97.5 <br />99% <br />Is the overfill prevention in proper operating condition <br />to respond when the substance reaches the <br />appropriate level? <br />® Yes <br />❑ No (Specify in V) <br />❑ Yes <br />❑ No (Specify in V)❑ <br />® Yes <br />No (Specify in V) <br />❑ Yes <br />E3 No (Specify in V) <br />IV, SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results❑Pass ® Fail <br />❑ Pass ® Fail [:3)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 />Both 87 and Diesel are above 95%. Both failed. 91 could not test. Could not remove fill cap and could not remove bucket. <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br />hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations, Title 23, <br />Division 3, C ter 16, Section 2637.2 and all the information contained herein is accurate. <br />UST Servic hnician Si ure <br />Audible and Visual <br />