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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page I of 1) <br /> Type of Action ❑Installation Test ❑Repair Test 0 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181399 05/18/20 <br /> Business Name(Same as Facility Name or-DBA-Doing Business As) <br /> Grant Line Shell <br /> - - - - - <br /> Business Site Address - City-- ZIP Code <br /> 2375 W Grant Line Rd. ITracy 95376 <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 /> Brian McPheely (408)971-2445 <br /> Contractor I 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 /> Franklin Fueling Site Safety#1014303708 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines(Specify): <br /> 0 Industry Code or Engineering Standard(Specify): PEI 1200 <br /> ❑ Engineered Method(Specify): <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages1 <br /> TANK ID:(By tank number,stored product,etc.) 1 Regular 2 Plus 13 Prem 4 Diesel <br /> Spill Container Manufacturer: I Philtite I Philtite I Philtite Philtite <br /> Method of Cathodic Protection: m Non-Metallic 0 Non-Metallic m Non-Metallic 0 Non-Metallic <br /> ❑Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(Specify in V.) ❑Other(Specify in V.) I ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 1 12 1 12 112 12 <br /> Depth of Spill Container: (Inches) 1 13112 1 13 14 121/4 <br /> Does the spill container have a 5 gallon capacity? I ❑Yes ©No I ❑Yes [0 No ©Yes ❑No ❑Yes ®No <br /> Method to Keep Spill Container Empty: m Drain Valve m Drain Valve m Drain Valve 0 Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑ Onsite Pump <br /> ❑ Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specifyin V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑Pass m Fail 1 ❑Pass 0 Fa7flq 0 Pass ❑Fail ❑Pass 0 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 /> 87,89&DSL Spill Buckets Do Not Hold 5 Gallons. <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=Identfication,UST=Underground Storage Tank,ICC=International Code Council <br />