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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 ❑x 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID Date of Spill Container Test <br />10/4/2018 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Colonial Energy #40134 <br />Business Site Address City ZIP Code <br />1434 W. Yosemite Ave Manteca 95337 <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 />Nick Janoe (916) 372-1885 <br />Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />617238 8712764 4/11/2019 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />OPW, Phil-TiteRE <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: 1 ❑x Manufacturer Guidelines (Specify) <br />❑ Industry Code or Engineering Standard (Specify): ENVIRONMENTAL HEAL-�H <br />❑ Engineered Method (Specify): DEPARRTMENT <br />I Attach the testing procedures and all documentation required to determine the results. <br />TANK ID: (By tank number, stored product, etc.) <br />Spill Container Manufacturer: <br />Inside Diameter of Spill Container: (Inches) <br />Depth of Spill Container: (Inches) <br />Does the spill container have a 5 gallon cal <br />Method to Keep Spill Container Empty: <br />87 Gasoline <br />OPW <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />11 1/4" <br />15" <br />91 Gasoline <br />OPW <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />11 1/4" <br />15" <br />? 2 Yes ❑ No 0 Yes ❑ No <br />❑x Drain Valve 0 Drain Valve <br />❑ Onsite Pump ❑ Onsite Pump <br />❑ Other (Specify in V.) ❑ Other (Specify in V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Diesel <br />OPW <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />11 1/4" <br />15" <br />0 Yes ❑ No <br />0 Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V) <br />❑ Yes ❑ No <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />Spill Container Test Results: Q Pass El_t2LIJ 0 Pass ❑ Fail r 0 Pass ❑ Fail II ❑ 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 /t/LC.'/�i l •_ / <br />e- <br />has more components than this form accornmodates, additional copies of this page may be attached. <br />CERS = Califomia Environmental Reporting System, ID = Identification, UST= Underground Storage Tank, ICC = Intemational Code Counal <br />