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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 ❑Q 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 1018363 11 /4/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> CHARTER WAY SHELL <br /> Business Site Address City ZIP Code <br /> 620 CHARTER WAY STOCKTON , CA 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 /> FELIX RAMIREZ ( 209 ) 744 - 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08- 1740 5-31 -20 8883072- UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 1009883708 11 /29/20 <br /> OPW # 104634 3- 14-20 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify) : OPW PHASE 1 LAKE TEST <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.) 87 91 DIESEL <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑x Non-Metallic N Non-Metallic Z Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V) ❑ Other (Specifyin V) <br /> Inside Diameter of Spill Container: (Inches) 11 11 11 <br /> Depth of Spill Container: (Inches) 15 15 15 <br /> Does the spill container have a 5 gallon capacity? 2 Yes ❑ No ❑x 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 /> ❑ Onsite Pump I ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specifyin V) ❑ Other (Specifyin V) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑x Pass ❑ Fail ❑x Pass ❑ Fail ❑x 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 /> ff 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 />