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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 /> 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 /> Jose Ochoa ( 888 ) 972 -7581 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 804431 & 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 : 0 Manufacturer Guidelines (Specify) : One hour hydrostatic test - Test measure . <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify): <br /> # of <br /> Attach the testing procedures and all documentation required to determine the results. Attached Pages0 <br /> TANK ID: (By tank number, stored product, etc.) T-5 91 T-6 Auto Diesel T-7 Waste Water <br /> Spill Container Manufacturer: Phil-Tite OPW OPW <br /> Method of Cathodic Protection : ❑x Non-Metallic ❑x Non-Metallic Z Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V) ❑ Other (Specifyin V.) <br /> Inside Diameter of Spill Container: (inches) 121212 � � <br /> i <br /> Depth of Spill Container: (Inches) 141418 � � <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No Il Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: Z Drain Valve 0 Drain Valve 0 Drain Valve ❑ 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 El Fail ZPass El Fail Z Pass ❑ Fail El 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 /> 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 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 />