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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> 11111321MOMMI! 11 SO iiiiiii!i <br /> Type of Action ❑ Installation Test ❑ Repair Test ® 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS IDDate of Spill Container Test <br /> 10187387 08/29/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Valero BP 29 <br /> Business Site Address City ZIP Code <br /> 1137 W . Lathrop Rd . Manteca 195336 <br /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Brian McPheely (408) 971 =2445 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8822062 111 /9/19 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 1014303708 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify): <br /> 0 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 /> TANK ID: B <br /> ( y tank number, stored product, etc.) 1 Regular 2 Prem 3 Diesel 14 <br /> Spill Container Manufacturer: Philtite Philtite Philtite <br /> Method of Cathodic Protection: ® Non4etallic ® Non-Metallic 0 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) 16 17 16 <br /> Does the spill container have a 5 gallon capacity? 2 Yes ❑ No © Yes ❑ No Q Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ® Drain Valve ® Drain Valve 0 Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ 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 ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail E] Pass [I Fall <br /> V. COMMENTS <br /> Any items marked "Fail"above must be explained in this section. Any additional comments may also be provided here. <br /> I <br /> i <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 = Intemational Code Council <br />