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Rmn'ECEIVEU <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> 14 1 <br /> Type oaf Alon - r ❑ Installation Test El Repair Test Z12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181387 1/9/2021 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Ryder Fuel Services <br /> Business Site Address City ZIP Code <br /> 3633 Duck Creek Rd. Stockton 195215 <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 /> Robert Henninger (408) 942-8686 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 396575 5252265-UT 6/21/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> FFS EVR PHASE I SYSTEMS-VR-101 Cert: 1004163708 Exp: 08/10/20 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines(Specify): <br /> 9 Industry Code or Engineering Standard(Specify): RP1200 <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.) Main DSL Reserve DSL New Oil Waste Oil <br /> Spill Container Manufacturer: Phil-Tite Phil-Tite Phil-Tite Phil-Tite <br /> Method of Cathodic Protection: ❑x Non-Metallic Z Non-Metallic ❑X Non-Metallic Z 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) 14.5" 14.25" 14.25" 14" <br /> Depth of Spill Container: (Inches) 15.5" 15.25" 15.5" 15" <br /> Does the spill container have a 5 gallon capacity? 2 Yes ❑No 2 Yes ❑No 0 Yes ❑No 2 Yes ❑No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑Q Drain Valve 9 Drain Valve ❑x Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑x Pass ❑Fail ❑x Pass ❑Fail I x❑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 /> 1 Hour Lake test was performed. <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=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br /> UN-108 www.unidocs.org 1/1 -Rev.06/14/18 <br />