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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 I] 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID Date of Spill Container Test <br />10181363 11/27/18 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />CHARTER WAY SHELL <br />Business Site Address City ZIP Code <br />620 CHARTER WAY STOCKTON, CA 95206 <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 />FELIX RAMIREZ <br />Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />0&1740 5-31-20 8883072-UT 11/22/201 8 <br />Spill Container Testing Training and Certifications (List applicable certifications.)Low <br />t <br />Franklin Fueling - EBW & Phil Tite #1009883708 11-16-18 <br />OPW #104634 3-14-20 <br />III. SPILL CONTAINER TESTING INFORMATION t big <br />Test Method Used: x❑ Manufacturer Guidelines (Specify): OPW WATER / TAPE ,• I �—ed�j\iyjlrt tAL <br />E]Industry Code or Engineering Standard (Specify): -IN t <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, storedproduct, etc.) 87 91 DIESEL <br />Spill Container Manufacturer: OPW OPW OPW <br />Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic ❑x 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) 11 11 11 <br />Depth of Spill Container: (Inches) 14 14 14 <br />Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No R Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No <br />Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ❑x Drain Valve ❑ 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 (Specify in V) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: ❑x Pass El Fail Fail ❑Q Fail 0 Pass Pass ❑ Fail El Pass EJ 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 /rrf� <br />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 = Identfication, UST= Underground Storage Tank, ICC = Intemafional Code Coundl <br />