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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 /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181913 02/12/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Shell <br /> Business Site Address City ZIP Code <br /> 16500 S. Harlan Road Lathrop, CA 95330 <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 /> Nik Zagorov (888) 500 - 2435 Ext.2 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 958763 5264361 05/08/2019 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW Phase 1 EVR #100908 exp. 04/06/2019 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑ Manufacturer Guidelines: (Specify) <br /> N Industry Code or Engineering Standard: (Specify) Hydrostatic One Hour Lake Test <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,stored product,etc.) 87 91 <br /> Spill Container Manufacturer: OPW OPW <br /> N Non-Metallic N Non-Metallic <br /> Method of Cathodic Protection ❑ Isolation ❑ Isolation <br /> ❑Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container:(Inches) 12 12 <br /> Depth of Spill Container:(Inches) 14 14 <br /> Does the spill container have a 5 gallon capacity? N Yes ❑ No N Yes ❑ No <br /> N Drain Valve N Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results N Pass ❑ Fail N Pass ❑ Fail <br /> V. COMMENTS <br /> All 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,chapter 16,section <br /> 2637.1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> Ir oV <br /> If the facility has more components than this f 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 />