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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Test ❑Repair Test ❑x 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10182131 5/6/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Pilot Flying J 618 <br /> Business Site Address City ZIP Code <br /> 1501 N Jack Tone Rd. 7Ripon 195366 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification) Phone# <br /> Austin Sterling (888) 972-7581 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 8 l Cont8g04431 A,13HAZ 8339953-UT 5/30/2021 <br /> 6�I Cert#r104tiO)R Training and Certifications(List applicable certifications.) <br /> Expiration: 8/19/2440 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines(Specify): <br /> p Industry code or Engineering Standard(Specify): Tape Measurer-Stop Watch -One hour hydrostatic test. <br /> ❑Engineered Method(Specify): <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages 5 <br /> TANK ID: (By tank number,stored product,etc.) T-8 Bio DSL <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> ❑Isolation ❑Isolation ❑ Isolation ❑ Isolation <br /> ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container:(Inches) 12° <br /> Depth of Spill Container:(inches) 14° <br /> Does the spill container have a 5 gallon capacity? Fil Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: 0 Drain Valve ❑Drain Valve ❑Drain Valve ❑Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in V.) 1 ❑Other(Specify in V.) 1 ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: 9 Pass ❑Fail I ❑Pass ❑Fail I ❑Pass ❑Fail ❑Pass ❑Fail <br /> V. COMMENTS <br /> Any items marked°Fail"above must be explained in this section. Any additional comments may also be provided here. <br /> t in 4 20 0 <br /> rcL 1-; TH <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTINCs/ <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations, Title 23, Division 3, <br /> Chapter 16,Section 2637.1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> ff 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=International Code Council <br />