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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 m 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181411 01/02/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Tracy Blvd Shell&Mini Mart <br /> Business Site Address City ZIP Code <br /> 3725 N Tracy Blvd. Tracy 95376 <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 /> (408)971-2445 <br /> Brian McPheely <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8822062 11/1/21 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW#104773 <br /> F.F.#1014303708 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: Manufacturer Guidelines(Specify): OPW <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> #of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. 1 <br /> TANK ID:(By tank number,stored product,etc.) 1 Regular 2 Plus 3 Prem 4 Diesel <br /> Spill Container Manufacturer: OPW OPW OPW OPW <br /> Method of Cathodic Protection: IZ Non-Metallic m Non-Metallic 0 Non-Metallic ®Non-Metallic <br /> ❑Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container:(inches) 12 12 12 12 <br /> Depth of Spill Container:(Inches) 14112 14 1/2 14 1/2 141/2 <br /> Does the spill container have a 5 gallon capacity? ®Yes ❑No EO Yes ❑No ©Yes ❑No 0 Yes [3 No <br /> Method to Keep Spill Container Empty: JZ Drain Valve JZ]Drain Valve m Drain Valve m Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in V.) I ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: m Pass ❑Fail I la Pass ❑Fail Pass ❑Fail 0 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 <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Cafrfomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br />