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UNDERGROUNDSTORAGETANK <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 <br />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 <br />1434 W. Yosemite Ave 7Manteca <br />City <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 />Nick Janoe <br />Phone # <br />(916) 372-1885 <br />Contractor I Tank Tester License # <br />617238 <br />ICC Certification # <br />8712764 <br />ICC Certification Expiration Date <br />4/11/2019 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />OPW, Phil-Tite <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />❑x Manufacturer Guidelines (Specify): <br />OPW <br />❑ Industry Code or Engineering Standard (Specify): <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 />87 Gasoline <br />91 Gasoline <br />Diesel <br />Spill Container Manufacturer: <br />OPW <br />OPW <br />OPW <br />Method of Cathodic Protection: <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 />❑ Non-Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />Inside Diameter of Spill Container: (Inches) <br />11 1/4" <br />11 1/4" <br />11 1/4" <br />Depth of Spill Container: (Inches) <br />15" <br />15" <br />15" <br />Does the spill container have a 5 gallon capacity? <br />[] Yes ❑ No <br />FAI Yes ❑ No <br />El Yes ❑ No <br />❑ Yes ❑ No <br />Method to Keep Spill Container Empty:x❑ <br />Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />0 Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑x Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />1V. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: IL 0 Pass ❑ Fail ❑ Pass ❑ Fail 11 ❑ Pass ❑ Fail 11 ❑ 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 ) •_ <br />gawed, <br />If the facility has more components than this form accommodates, additional copies of this page may be attached. <br />CERS = Califomia Environmental Reporting System, ID = Identification, UST= Underground Storage Tank, ICC = International Code Council <br />