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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 ® 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />10181487 <br />Date of Spill Container Test <br />05/21/20 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />Speedway 4612 <br />Business Site Address <br />2448 W Kettleman Ln. <br />City <br />Lodi <br />ZIP Code <br />95242 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) <br />Brian McPheely <br />Phone # <br />(408) 971-2445 <br />Contractor / Tank Tester License # <br />485184 <br />ICC Certification # <br />8822062 <br />ICC Certification Expiration Date <br />11/1/21 <br />— — <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />OPW # 104773 <br />Franklin Fueling Site Safety # 1014303708 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />❑ Manufacturer Guidelines (Specify): <br />® Industry Code or Engineering Standard (Specify): PE11200 <br />❑ Engineered Method (Specify): <br />Attach the testing procedures and all documentation mqulmd to determine the results. <br /># of Attached Pages 1 <br />TANK ID: (By tank number, stored product, etc.) <br />1 Regular <br />2 Prem <br />3 Diesel <br />Spill Container Manufacturer: <br />Philtite <br />Philtite <br />Philtite <br />Method of Cathodic Protection: <br />® Non-Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />la Non-Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />m Non-Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑ Non-Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />Inside Diameter of Spill Container: (Inches) <br />12 <br />12 <br />12 <br />Depth of Spill Container: (Inches) <br />15114 <br />151/4 <br />15 <br />Does the spill container have a 5 gallon capacity? <br />0 Yes ❑ No <br />© Yes ❑ No <br />© Yes ❑ No <br />❑ Yes ❑ No <br />Method to Keep Spill Container Empty: <br />0 Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />m Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />m Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: <br />O Pass ❑ Fail 1 0 Pass ❑ Fail 1 <br />0 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 />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 />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 />