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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 ❑0 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID Date of Spill Container Test <br />10181307 5/27/2020 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />REFUEL PETROLELUM - REFUEL CIRCLE K <br />Business Site Address City ZIP Code <br />419 S. MAIN STREET �MANTECA,CA 95366 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the /CC Certification.) Phone # <br />ZANE NIMMO (209) 744-0112 <br />Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />04-1676 Ex. 3/31/22 8883064 -UT 6/2/2021 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tite #10009843708 Ex.11/29/2020 <br />OPW #104-632 Ex. 3/17/2022 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: ❑x Manufacturer Guidelines (Specify): PHIL TITE PHASE I LAKE TESTING <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.) <br />Spill Container Manufacturer: <br />Method of Cathodic Protection: <br />Inside Diameter of Spill Container: (Inches) <br />Depth of Spill Container: (Inches) <br />Does the spill container have a 5 gallon capacity? <br />Method to Keep Spill Container Empty: <br />IV. <br />Spill Container Test Results: <br />1 - 91 OCT <br />PHIL TITE <br />❑x Non -Metallic <br />❑ Isolation <br />❑ Other (Specifyin V.) <br />12 <br />14 1/2 <br />2 - 87 OCT <br />PHIL TITE <br />x❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />12 <br />15 <br />❑x Yes ❑ No ❑x Yes ❑ No <br />0 Drain Valve 0 Drain Valve <br />❑ Onsite Pump ❑ Onsite Pump <br />❑ Other (Specifyin V.) ❑ Other (Specify in V.) <br />SUMMARY OF TESTING RESULTS <br />❑ Pass ❑x FaiiII 0 Pass ❑ Fail IF <br />3 - DIESEL <br />PHIL TITE <br />❑x Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />12 <br />15 <br />0 Yes ❑ No <br />0 Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑ Yes ❑ No <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />0 Pass ❑ Fail 11 ❑ Pass ❑ 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 />91 PHIL TITE DIRECT BURY SPILL BUCKET, FAILED DUE TO BAD DRAIN VALVE ONLY. <br />NO PARTS ON SITE WILL NEED REPAIRED AND RETESTED <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, <br />Chapter 16, Section 2637.1 and all the information contained herein is accurate. <br />UST Service Technician Signature <br />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 Council <br />