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ij UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page -I of 1 ) t �1 Type of Action ❑ Installation Test ❑ Repair Test hLI '92 o tYi Te t� ' i 'ol7 i-' I . FACILITY INFORMATION ' 1 ` " M T7;'P CERS ID Date of Spill Container Test 10180657 5/22/2020 Business Name (Same as Facility Name or DBA-Doing Business As) SYNERGY - CENTRAL GAS Business Site Address City ZIP Code 642 N . HUNTER STREET STOCKTON , CA 95202 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # ZANE NIMMO (209 ) 744 - 0112 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 04- 1676 Ex . 3/31 /22 8883064 - UT 6/ 1 /2021 Spill Container Testing Training and Certifications (List applicable certifications.) Franklin Fueling - EBW & Phil Tite # 10009843708 Ex . 11 /29/2020 OPW # 104-632 Ex . 3/ 17/2022 III . SPILL CONTAINER TESTING INFORMATION Test Method Used : Zx Manufacturer Guidelines (specify) : O P W PHASE I LAKE TESTING ❑ Industry Code or Engineering Standard (Specify) : Z Engineered Method (Specify) : # of Attached Pages Attach the testing procedures and all documentation required to determine the results. TANK ID : (By tank number, storedproduct, etc.) 91 OCTANE 87 OCT - 1 [8111117ET - 2 DIESEL # 2 Spill Container Manufacturer: O P W O P W W O P W Method of Cathodic Protection: ❑x Non-Metallic I] Non-Metallic on-Metallic ❑x Non-Metallic ❑ Isolation Z Isolation solation ❑ Isolation ❑ Other (Specifyin V.) ❑ Other (Specify in V) ther (Specifyin V.) Z Other (Specify in V) Inside Diameter of Spill Container: (Inches) 11 1 /2 11 1 /2 11 1 /2 11 1 /2 Depth of Spill Container: (Inches) 13 14 14 14 Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No Zx Yes Z Noes Z No 9 Yes Z No Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve rain Valve 0 Drain Valve Z Onsite Pump ❑ Onsite Pump ❑ Onsite Pump Z Onsite Pump Z Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : FE�[E Pass ❑ Fail (] Pass ❑ Fail Zx Pass ❑ Fail ❑x Pass ❑ Fail V. COMMENTS Any items marked "Fail" above must be explained in this section . Any additional comments may also be provided here. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations , Title 23 , Division 3 , Chapter 16 , Section 2637 . 1 and all the information contained herein is accurate. �I UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = Cafrfomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council