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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 /> 5/8/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Pilot Flying J 618 <br /> Business Site Address City ZIP Code <br /> 1501 N Jack Tone Rd . Ripon 95366 <br /> 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Jose Ochoa ( 888 ) 972 -7581 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 804431 A , B HAZ 8004551 - UT 12/27/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW Cert# 100826 <br /> Expiration : 1 - 19-20 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : Rx Manufacturer Guidelines (Specify) : One hour hydrostatic test - Test measure . <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> i <br /> ❑ Engineered Method (Specify) : <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. 0 <br /> TANK ID : (By tank number, storedproduct, etc.) T- 1 Diesel T-2 Diesel T-3 Diesel T-487 <br /> Spill Container Manufacturer: PhikTlte OPW OPW Phil-Tite <br /> Method of Cathodic Protection : ❑x Non-Metallic ❑x Non-Metallic ❑x Non-Metallic ❑Q Non-Metallic <br /> I <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> R Other (Specifyin V.) ❑ Other (Specifyin V) ❑ Other (Specifyin V) ❑ Other (Specifyin V) <br /> Inside Diameter of Spill Container: (Inches) 12 " 12 " 12 If 12 " <br /> Depth of Spill Container: (Inches) 14 " 1 $ " 1814 � � <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑x Yes R No 0 Yes ❑ No R Yes ❑ No <br /> Method to Keep Spill Container Empty: Rx Drain Valve Z Drain Valve ❑x Drain Valve Z Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : Z Pass R Fail Z Pass R Fail ❑Q Pass ❑ Fail Z 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 /> 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 /f <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 Council <br /> i <br />