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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM ( Page 1 of 1 ) <br /> Type of Action F1Installation Test ❑ Repair Test ® 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID of Spill Container Test <br /> 10181229 71Date <br /> 1 /24/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Shell/ Tesoro <br /> Business Site Address City ZIP Code <br /> 35 N . Cherokee Ln . Lodi 95240 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shovvn on the ICC Certification.) Phone # <br /> Brian McPheely (916) 649-8670 <br /> Contractor t Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8822062 11 /9/19 <br /> Spill Container Testing Training and Certifications (List applicable certifications) <br /> OPW - 104773 <br /> 10143036708 <br /> Ill . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ® Manufacturer Guidelines (Specify) : Opw <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify): <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> TANK ID : (By tank number, stored product, etc.) 1 Regular 2 Prem 3 Prem 4 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection : ® Non- Metallic O Non-Metallic O 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) 12 12 12 <br /> Depth of Spill Container: (Inches) 123/4 13 121 /2 <br /> Does the spill container have a 5 gallon capacity? O Yes ❑ No O Yes ❑ No O Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: O Drain Valve O Drain Valve O Drain Valve ❑ Drain Valve <br /> O Onsite Pump O Onsite Pump O 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 : ® Pass E] Fail O Pass ❑ Fail =OP ass E] Fail En] 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 /> Replaced the 91 Fill Adapter and Cap - Retested & Passed . <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 31 <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 /> I <br /> l <br />