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t <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑x Installation Test ❑ Repair Test ❑ 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Valero <br /> Business Site Address City ZIP Code <br /> 1210 E Hammer Ln Stockton 95210 <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 /> Chris Adams (209 ) 461 -6337 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1001331 A-HAZ 8230218 4/20/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> FFS Cert# 104863710 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : x❑ Manufacturer Guidelines (Specify): Hydrostatic <br /> ❑ Industry Code or Engineering Standard (Specify): <br /> ❑ Engineered Method (Specify): <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages <br /> TANK ID: (By tank number, stored product, etc.) 91 Diesel 87 <br /> Spill Container Manufacturer: Phik"rite Phil-Tite PhikTite <br /> Method of Cathodic Protection: Non-Metallic x❑ Non-Metallic 0 Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (SpecHy in V.) ❑ Other (Specify in V.) ❑ Other (Specify In V.) <br /> Inside Diameter of Split Container: (Inches) <br /> Depth of Spill Container: (inches) 15 15 15° <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑x Yes ❑ No I] Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: Z Drain Valve Q Drain Valve 0 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. SUMMARYOF TESTING RESULTS , <br /> Spill Container Test Results: ❑x Pass ❑ Fail ZPass ❑ Fail 21 Pass ElFail 171Pass ElFail <br /> V. COMMENTS <br /> .. .. .. . .. . . . .. .. . <br /> Any items marked TO' above must be explained in this section. Any additional comments may also be provided here. <br /> a.- <br /> x <br /> MAI <br /> VI . CERTIFICATION BY; UST SERVICE 'TECHNICIAN ' CONDU <br /> I hereby certify that the spill containers were tested in accordance with California Code of Reg utatdo Tltte 24lbivision 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 = Calffomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />