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UNDERGROUND STORAGE TANK OVERFILL, PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action El installation Inspection ❑ Repair Inspection ❑ 36 Month Inspection 1 . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10/8/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Shell Business Site Address City ZIP Code 620 VV - WrIWI LV-41pr Pklll) je, is V4 Stockton 95206 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone It Chris Adams (209 ) 461 - 6337 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 1001331 XHAZ 8230218 4/17/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) OPW Cert# 100305 Exp 5/23/2021 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify): Used : ❑ 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.) Diesel 87 What is the tank inside diameter? (Inches) 92 " 91 to Is the fill piping secondarily contained ? ❑ Yes 0 No ❑ Yes E No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes El No ❑ Yes 2 No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPW OPW What is the overfill prevention equipment response ❑x Shuts Off Flow Z Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated? ❑x Restricts Flow 0 Restricts Flow ❑ Restricts Flow ❑ Restricts Flow (Check all that apply.) ❑ AN Alarm ❑ AIV Alarm ❑ AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping? ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 801 /2 80112 What is the percent capacity of the tank at which the overfill prevention equipment activates? 93 % 93 % Is the overfill prevention in proper operating condition ❑x Yes 21 Yes ❑ Yes ❑ Yes to respond when the substance reaches the appropriate level? ❑ No (Specify In V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) 1V. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results 0 Pass ❑ Fail 19 Pass ❑ Faii ❑ Pass ❑ Fail ❑ 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 equipment was inspected In accordance with California Code of Regulations , Title 23 , Division 3 , Chapter 16, Section 2637. 2 and all the Information contained herein Is accurate. UST Service Technician Signature � .rYGZ®GJ�'Yld� If 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 = International Code Council, AN = Audible and Visual