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UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Pagel 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 />10169781 10/12/2018 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />Colonial Energy # 40134 <br />Business Site Address <br />1434 W. Yosemite Ave. <br />City <br />Manteca <br />ZIP Code <br />195337 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) <br />Rey Hernandez <br />Phone # <br />(916) 372-1885 <br />Contractor / Tank Tester License # <br />617238 <br />ICC Certification # <br />8712763 <br />ICC Certification Expiration Date <br />Spill Container Testing Training and Certifications (List applicable certifications.)Lj <br />OPW, Phil-Tite <br />DEC 0 5 2018 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />❑x Manufacturer Guidelines (Specify): <br />Lake Test ENI\fIP - <br />❑ Industry Code or Engineering Standard (Specify): DEPARTMENT <br />❑ Engineered Method (Specify): <br />Attach the testing procedures and all documentation required to determine the results. <br /># of Attached Pages <br />TANK ID: (By tank number, stored product, etc.) <br />DIESEL <br />Spill Container Manufacturer: <br />OPW <br />Method of Cathodic Protection: <br />❑ Non-Metallic <br />❑x Isolation <br />❑ Other (Specify in V.) <br />❑ Non-Metallic <br />❑ Isolation <br />❑ Other (specify in V) <br />❑ Non-Metallic <br />❑ Isolation <br />❑ Other (Specify in V) <br />❑ Non-Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />Inside Diameter of Spill Container: (Inches) <br />11 „ <br />Depth of Spill Container: (Inches) <br />15" <br />Does the spill container have a 5 gallon capacity? <br />0 Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Method to Keep Spill Container Empty: <br />❑x Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: <br />❑x 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 />Arrived on sit to replace the Diesel spill bucket due to it failing during the overfill inspection test. <br />Replaced diesel spill bucket obtained passing results. <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br />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 a,*ommodates, additirf I copies of this page may be attached. <br />CERS = California Environmental Reporting System, ID = Identfication, UST= Underground Storage Tank, ICC = International Code Council <br />