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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation fest ❑ Repair Test N 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10182131 5/5/2020 <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. Ripon 95366 <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 /> 804431 A,B HAZ 8339953-UT 5/30/2021 <br /> OW <br /> Container Testin Trainin and Certifications Listapplicable certifications.) <br /> IS 11 <br /> Cert# 1040489 Phil�tite Cert# 1011003708 <br /> Expiration: 8/19/20 Expiration: 11/17/21 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines(Specify): <br /> N 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-1 Diesel T-2 Diesel T-3 Diesel T-4 87 <br /> Spill Container Manufacturer: Phil-Tite OPW OPW Phil-Tite <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic ❑x Non-Metallic ❑x 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" 1211 1 211 1 21f <br /> Depth of Spill Container:(Inches) 14" 18" 1811 14" <br /> Does the spill container have a 5 gallon capacity? i]Yes ❑No ❑x Yes ❑ No ❑x Yes ❑ No I]Yes ❑No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve I] Drain Valve Z 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 ❑x Pass ❑ Fail I ❑x Pass ❑ Fail ❑x 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 /> 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 />