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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 /> 10169775 4/8/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Colonial Energy #40138 <br /> Business Site Address City ZIP Code <br /> 14000 E Highway 88 Lockeford 95237 <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 /> Maxwell Hines (916) 372-1885 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 617238 8750053 10/24/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW, Phil-Tite <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): OPW <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,storedproduct,etc.) 87 91 Diesel <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑ Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> ❑x Isolation ❑x Isolation ❑x 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) 11.5" 11.5" 11.5" <br /> Depth of Spill Container: (Inches) 10.25" 10.5" 10.5" <br /> Does the spill container have a 5 gallon capacity? El Yes ❑No El Yes ❑No ❑X Yes ❑No ❑Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ❑x Drain Valve ❑ Drain Valve <br /> ❑x Onsite Pump ❑x Onsite Pump ❑x 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: TF❑x Pass ❑Fail ❑x Pass ❑Fail ❑x Pass El 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 /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <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 /> MGU' h`ln2J <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 />