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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 ® 12 Month Test <br /> L FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10184365 12/ 12/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Gas 4 Less <br /> Business Site Address City ZIP Code <br /> 3408 Manthey Rd , Stockton 95206 <br /> 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) 7(P408) <br /> hone # <br /> Kristopher Bell 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8833000 7/22/20 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> F . F . # 1004933708 i <br /> OPW #902968 `� • i <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : ,JAI\1 I <br /> ® Industry Code or Engineering Standard (Specify): PEI 1200 <br /> `, pail ti . 41i , ; � r `� A � 3 t 0i <br /> : . . : : <br /> ❑ Engineered Method (Specify): FiNT <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 Prem 3 4 <br /> Spill Container Manufacturer: PhikTite PhikTite <br /> Method of Cathodic Protection: ® Non-Metallic V1 Non-Metallic ❑ 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) 13" 13" <br /> Depth of Spill Container: (Inches) 13" 13" <br /> Does the spill container have a 5 gallon capacity? ❑ Yes D No ❑ Yes [21 No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ® Drain Valve ® Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> j ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> j Spill Container Test Results: ❑ Pass ® Fail ❑ Pass ® Fail ❑ Pass ❑ Fail ❑ 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 /> Buckets don't hold 5 gallons . <br /> Via 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 /> i' 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 />