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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection 10 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181913 02/12/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Shell <br /> Business Site Address City ZIP Code <br /> 16500 S. Harlan Road Lathrop, CA 95330 <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 /> Nik Za orov 888 500-2435 Ext.2 <br /> ContractorfTank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 958763 15264361 05/08/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> OPW Phase 1 EVR#100908 exp. 04/06/2019 <br /> Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: Z Manufacturer Guidelines(Specify)OPW X1 SO TEST 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:8 <br /> Tank ID:(By tank number,stored product,etc.) 87 91 <br /> What is the tank inside diameter?(Inches) 119.625 119.625 <br /> Is the fill piping secondarily contained? ❑Yes ® No ❑Yes Z No <br /> Is the vent piping secondarily contained? ❑Yes ® No ❑Yes Z No <br /> OPW OPW <br /> Overfill Prevention Equipment Manufacturer(s) <br /> 61 SO 61 SO <br /> What is the overfill prevention equipment Z Shuts Off Flow Z Shuts Off Flow <br /> response when activated? ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ® No ❑Yes Z No <br /> At what level in the tank is the overfill prevention 99.75 105.00 <br /> set to activate?(Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which 90 94 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating Z Yes ®Yes <br /> condition to respond when the substance ❑ No ❑ No <br /> reaches the appropriate level? (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results 11 Z Pass ❑ Fail I Z Pass ❑ Fail <br /> V. COMMENTS <br /> All items marked"Fail'must be explained in this section. Any additional comments may also be providQ=e n <br /> 1111111� %MOW 29— a ft— <br /> MAR <br /> MA 1 1 N19 <br /> ENVIRUW,' <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,division 3, <br /> chapter 16,section 2637.2 and all the information contained herein is accurate. <br /> UST Service Technician Signature ' ` <br /> N Z040 roe/ <br /> If the facility has more components than this fomMccommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council,A/V=Audible and visual <br />