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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 /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181331 1 /23/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> BFS Tracy Inc. (Valero # 3698) <br /> Business Site Address City ZIP Code <br /> 153 E . 11th St. Tracy 95376 <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 /> Guadalupe Sanchez (925) 470 - 0803 Ext. <br /> Contractorrrank Tester Ucense # ICC Certification # ICC Certification Expiration Date <br /> 1005444 5250451 4/8/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> FFS EVR Phase I Systems # 1031393709 Expires: 3/4/2020 OPW # 016375 Expires; 6/18/201, W- <br /> Ill. <br /> /18/2019'III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ; ; t ; � �,c J <br /> ❑ Manufacturer Guidelines: (Specify) <br /> ® Industry Code or Engineering Standard: (Specify) PEI/RP1200- 17 <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.) T1 : 87 Syphon T2 : 87 Master T3: 91 <br /> Spill Container Manufacturer PhiiJite Phil-Tite Phil-Tite <br /> ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection ® Isolation ® Isolation ® Isolation ❑ Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify In section V.) (Specify in section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container (inches) 103/4 103 103/4 <br /> Depth of Spill Container. (Inches) 14 14" 133/4 <br /> Does the spill container have a 5 gallon capacity? ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No <br /> ® Drain Valve ® Drain Valve ® Drain Valve ❑ Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (SpecHy in section V.) <br /> N. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ❑ Pass ® Fait 11 ❑ Pass ® Fail ❑ Pass ® Fail ❑ Pass ❑ Fall <br /> V. COMMENTS <br /> All items marked "Fall" above must be explained in this section. Any additional comments may also be provided here. <br /> The spill buckets passed the hydrostatic test for an hour, but do not hold the 5 gal capacity. Spill Buckets hold <br /> approximately 4 7/8 gallons . To accomplish the 5 gallons, the 4" riser needs to be replaced or cut and <br /> threaded in order to fit either the existing Phil-Tite 31 /2 gallon bucket or install the new PhikTite 5 gallon spill <br /> bucket. Spill Buckets are secondarily contained (Fill Sumps) <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, chapter 16, section <br /> 2637.1 and all the information contained herein Is accurate. <br /> UST Service Technician Signature <br /> ff the facility has more components than dils form accothmodates, additional copies of this page maybe attached. <br /> RFRR = rW1fh „ia FmAmutunnla! Rarvulinn Sv¢farn in a trianmutAtinn i RT = i tnrlamrru mil atrwxw hank ir.( = intamaHnna! rnw (rm a,effl <br />