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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 Date of Spill Container Test <br /> 10411900 05/07/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Shell # 68221 <br /> Business Site Address City ZIP Code <br /> 2705 Country Club Stockton 95204 <br /> 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the IGC Certification.) Phone # <br /> Kristopher Bell J(408 ) 971 -2445 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8833000 7/22/20 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 10044933708 <br /> Ili . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> ® 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 <br /> 1 <br /> TANK ID: (By tanknumber, stored product, etc.) 1 Regular 2 Prem 3 Diesel 4 <br /> Spill Container Manufacturer: Phil-rite Phil-Tite PhikTite <br /> Method of Cathodic Protection: ® Non-Metallic ® Non-Metallic ® Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specifyin V.) Other (Specifyin V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 13" 13" _ 13" <br /> Depth of Spill Container: (inches) 141 /2 13" 161 /211 <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: ® Drain Valve ® Drain Valve ® Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump El Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specifyin V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ® Pass ❑ Fail ❑ 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 /> 91 Spill Bucket doesn't hold 5 gallons per Stacy Rivera - no need to test automatic failure . <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 />