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01 <br />UNDERGROUND STORAGE TANK <br />If the facility has more components than this form accommodates, additional copies of this page may be attached. <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Test ❑ Repair Test Fxl 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Spill Container Test <br />10157477 <br />9/11/2018 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Shell Oil Products <br />Business Site Address City <br />ZIP Code <br />3515 Navy Dr. Stockton <br />95203 <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 />PATRICK C. BANBURY 7714-920-5476 <br />Contractor / Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />5S8p8098 <br />5254955 <br />1/4/2019 <br />g <br />Tai STS 1t0U17337n_gand Certifications (List applicable certifications.) <br />INIOContainer <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />❑ Manufacturer Guidelines (Specify): <br />❑x Industry Code or Engineering Standard (Specify): 5 GALLON TEST WATER <br />❑ Engineered Method (Specify): <br /># of Attached Pages1 <br />Attach the testing procedures and all documentation required to determine the results. <br />TANK ID: (By tank number, stored product, etc.) <br />Slop tank <br />Spill Container Manufacturer: <br />OPW <br />7E]Non-Metallic <br />Method of Cathodic Protection: <br />❑ Non -Metallic <br />❑ Non -Metallic <br />❑ Non -Metallic <br />x❑ Isolation <br />❑ Isolation <br />❑ Isolation <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V) <br />❑ Other (Specify in V) <br />❑ Other (Specify in V.) <br />Inside Diameter of Spill Container: (Inches) <br />11" <br />Depth of Spill Container: (Inches) <br />10.75" <br />Does the spill container have a 5 gallon capacity? <br />❑x Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Method to Keep Spill Container Empty: <br />❑x Drain Valve <br />❑ Drain Valve <br />❑ Drain Valve <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V) <br />IV, SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: 9 Pass ❑ Fail ❑Pass ❑Fail EE❑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 />Pat Sag&" <br />CERS = Calffomia Environmental Reporting System, ID =Identification, UST= Underground Storage Tank, ICC = International Code Coundl <br />