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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 Z 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10184919 12/28/ 18 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> GAS DEPOT <br /> Business Site Address City ZIP Code <br /> 1330 E . YOSEMITE AVE MANTECA, CA 95336 <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 /> EDWARD STEARNS (209 ) 744-0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 9/30/20 8883080 - UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 1009893708 Ex. 11 /29/2020 <br /> OPW # 104-635 Ex. 3/ 14/2020 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify) : LAKE TEST <br /> I <br /> i <br /> ❑ Industry Code or Engineering Standard (Specify) : <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.) 1 -87 2- 91 3- DIESEL <br /> E <br /> Spill Container Manufacturer: CNI CNI CNI <br /> Method of Cathodic Protection : Z Non-Metallic 0 Non-Metallic ❑x Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> E] Other (Specifyin V.) 171 Other (Specifyin V.) El Other (Specifyin V) ❑ Other (Specifyin V.) <br /> Inside Diameter of Spill Container: (inches) 11 11 11 <br /> Depth of Spill Container: (Inches) 14 14 15 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑X Yes ❑ No El Yes ❑ No ❑ Yes ❑ No <br /> I Method to Keep Spill Container Empty: ❑x Drain Valve El Drain Valve D Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> f ❑ Other (Specifyin V) ❑ Other (Specifyin V) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> i, <br /> Spill Container Test Results : 9 Pass ❑ Fail Z Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail <br /> E V. COMMENTS <br />= Any items marked "Fail' above must be explained in this section. Any additional comments may also be provided here <br /> r <br /> . ,n <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CON DU 1 A I `� i <br /> 1 hereby certify that the spill containers were tested in accordance with California Code of a ut4ti`orW, ITIii 23 , Division 3 , <br /> Chapter 16, Section 2637 . 1 and all the information contained herein is accurate. <br /> UST Service Technician Signature ,p <br /> �t <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 Counal <br />