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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Test ❑ Repair Test Z 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 Narne or DBA-Doing Business As) <br /> Pilot Flying J 618 <br /> Business Site Address City ZIP Code <br /> 1501 N Jack Tone Rd. Ripon 95366 <br /> It. 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 Dale <br /> 804431 A,13 HAZ 8339953-UT 5/30/2021 <br /> SOII Cern er1040estiinggTraining and Certifications(List applicable certifications.) <br /> Expiration: 8/19/2440 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines(Specify): <br /> Z Industry Code or Engineering standard (Specify): Tape Measurer- Stop Watch - One hour hydrostatic test. <br /> ❑Engineered Method(Specify): <br /> #of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. 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) 1211 <br /> Depth of Spill Container: (Inches) 14° <br /> Does the spill container have a 5 gallon capacity? l]Yes ❑No ❑Yes ❑ No ❑Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑x Pass ❑ Fail ❑ Pass ❑ Fail ❑ 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.y 3 202v <br /> EWRONMENI AL HEALT ' <br /> DEPARTMENT <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 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 /> 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=International Code Council <br />