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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Test m Repair Test ❑ 12 Month Test <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10184365 02/06/20 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Gas 4 Less <br /> Business Site Address City ZIP Code <br /> 3408 Manthey Rd . [Stockton 95206 <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 /> Hunter Gustin (408) 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 19139238 5/14/21 <br /> Spill Container Testing Training and Certifications (List applicable certifications) <br /> F . F. # 1019523709 <br /> film SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify): <br /> JZ Industry Code or Engineering Standard (Specify): PEI 1200 <br /> ❑ Engineered Method (Specify): <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages 1 <br /> TANK ID: (By tank number, stored product, etc.) 1 Regular 2 Prem <br /> Spill Container Manufacturer: Phil-Tite Phil-Tite <br /> Method of Cathodic Protection : 0 Non-Metallic m 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) 13" 13" <br /> Depth of Spill Container: (inches) 13" 13" <br /> Does the spill container have a 5 gallon capacity? © Yes ❑ No © Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: 91 Drain Valve 0 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: 21 Pass ❑ Fail m 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. <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 2j, Division 3, <br /> Chapter 16, Section 2637. 1 and all the information contained herein is accurate. 1 j <br /> UST Service Technician Signature ^ <br /> If the facility has more components than thfs form accommodates, additional copies of this page may be attached. <br /> CERS = Callomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = international Code Council <br /> cul f ; r k. t <br /> � r <br />