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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 ❑Q 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10169823 1 /3 /2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Colonial Energy <br /> Business Site Address City ZIP Code <br /> 192 Lathrop Road ILathrop 95330 <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 /> Anthony Reyes ( 916 ) 372 - 1885 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 617238 8293772 9/ 16/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW Tech# 103920 , PhikTite Tech# 1003213709 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify) : <br /> Lake Test <br /> ❑ Industry Code or Engineering Standard (Specify) : <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.) 87 Master 87 Slave 91 Gasoline Diesel <br /> Spill Container Manufacturer: OPW OPW OPW OPW <br /> Method of Cathodic Protection: ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> (] Isolation 9 Isolation Pfl Isolation ❑x Isolation <br /> ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) <br /> Inside Diameter of Spill Container: (inches) 11 . 5 11 . 5 11 . 5 11 . 5 <br /> Depth of Spill Container: (Inches) 15 15 15 15 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑x Yes ❑ No M Yes ❑ No 0 Yes ❑ No <br /> Method to Keep Spill Container Empty. ❑x Drain Valve ❑x Drain Valve X 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 (Specifyin V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : 9 Pass ❑ Fail ❑x Pass ❑ Fail ❑x Pass ❑ Fail ❑x 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 /> . ia . <br /> ,JAN 2 3 2020 <br /> ENVIRONMENTAL HEALTH <br /> Vi . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING TH1STING <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 SignatureI A �'� <br /> of <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Calffomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />