Laserfiche WebLink
r <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10089340 4/11 /2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> 99 Shell <br /> Business Site Address City ZIP Code <br /> 7700 Moreland St Stockton 95212 <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 /> Timothy Capehart (800) 339-9930 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 804904 8414476 3/3/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> Opw 0167682 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑ Manufacturer Guidelines (Specify) : <br /> Used : <br /> ❑x Industry Code or Engineering Standard (Specify) : PEI- 1200 <br /> ❑ Engineered Method (Specify) : <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 3 <br /> TANK ID : (By tank number, stored product, etc.) Unleaded Premium Diesel <br /> What is the tank inside diameter? (Inches) 119 .0" 119. 0" 119 . 0" <br /> Is the fill piping secondarily contained? 0 Yes ❑ No El Yes ❑ No Z Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑x Yes ❑ No 0 Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) Opw Opw Opw <br /> 61 -so 61 -so 61 -so <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ' ❑x Shuts Off Flow ' ❑x Shuts Off Flow ' ❑ Shuts Off Flow ' <br /> when activated ? <br /> ❑ <br /> (Check all that apply.) ❑ <br /> Restricts Flow ' Restricts Flow 2 El Restricts FIow2 El Restricts Flow 2 <br /> ❑ A/V Alarm ' ❑ AN Alarm ' ❑ A/V Alarm 3 ❑ AN Alarm ' <br /> Are flow restrictors installed on vent piping ? ❑ Yes M No ❑ Yes ❑X No ❑ Yes 0 No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set ' 2 ] ' 2 3 , 2 ] , 2 ] <br /> to activate? (Inches from bottom of tank.) 104.0• 107,0" / 106,5 / <br /> What is the percent capacity of the tank at which the ' 2 3 , 2 ] , 2 3 , 2 ] <br /> overfill prevention equipment activates? 92.5% / s5i / 941 <br /> Is the overfill prevention in proper operating condition ❑x Yes X Yes ❑x Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level ? ❑ No (Specify in V.) [:1 No (Specify in V.) ❑ No (Specify in V.) El N0 <br /> (Specify <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ❑ Fail ❑x Pass ❑x Fail 0 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 /> ru "t <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING TAWItS ibN <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 2/6`37 . 2 and all the information contained herein is ade�41# 0 <br /> UST Service Technician Signatur%M�'' WPARTMENT <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, AN = Audible and Visual <br /> UN -109 www. unidocs .org 111 - Rev. 06/14/18 <br />