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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 /> 10181381 1 /22/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> RIPON SHELL <br /> Business Site Address City ZIP Code <br /> 341 E MAIN STREET ] RIPON , 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 /> DAVID WINKLER (209 ) 744- 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08 - 1739 Ex . 3/31 /20 8883059- UT 1 /29/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 10009853708 Ex . 11 /29/20 <br /> OPW # 104-633 Ex . 3/14/2020 a <br /> III . SPILL CONTAINER TESTING INFORMAtION' <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify) : WATER TEST I. ® 7019 <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify) : El VIRONMENT1116 HEALTH <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> i <br /> TANK ID : (By tank number, stored product, etc) 87 91 <br /> Spill Container Manufacturer: OPW OPW <br /> Method of Cathodic Protection : ❑x Non-Metallic ❑x Non-Metallic ❑ 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 <br /> Depth of Spill Container: (Inches) 14 14 <br /> Does the spill container have a 5 gallon capacity? R Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ElOther (Specify in V.) ❑ Other (Specify in V.) El Other (Specifyin V) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : Q Pass ElFail Ix Pass ❑ Fail L1Pass E] Fail ❑ Pass [j 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 /> 1 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 ^ 1 <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 = Intemational Code Council <br />