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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Action [] Installation Test ❑ Repair Test ❑ 12 Month Test I . FACILITY INFORMATION CERS ID Date of Spill Container Test 10/8/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Shell Business Site Address City ZIP Code 620 �( �� 1' �11 (?t% , atm 12 I tru Stockton 95206 II . UNDERGROUNDS ORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # Chris Adams (209 ) 461 -6337 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 1001331 XHAZ 8230218 4/17/2020 Spill Container Testing Training and Certifications (List applicable certifications.) OPW Cert# 100305 Exp 5/23/2021 Ills SPILL CONTAINER TESTING INFORMATION Test Method Used : ❑x Manufacturer Guidelines (Specify): Hydrostatic ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product etc.) Diesel 87 Spill Container Manufacturer: OPW OPW Method of Cathodic Protection: ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic Isolation JO isolation ❑ Isolation ❑ Isolation ❑ Other (specify in V) ❑ Other (Specify in V.) ❑ Other (specify in v.) ❑ Other (specify in V) Inside Diameter of Spill Container: (inches) Depth of Spill Container: (Inches) 131 /4 127/8 Does the spill .container have a 5 gallon capacity? El Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Method to Keep Spill Container Empty: ❑x Drain Valve D Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) 1V. SUMMARY OF TESTING RESULTS Spill Container Test Results E Pass ❑ Fail ElPass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked `Fail' above must be explained in this section. Any additional comments may al ow itr - > . .. c � 019 IWRO VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THI ry p., I hereby certify that the spill containers were tested in accordance with California Code of Regulations ,' It ; bi,'rision 3, Chapter 16, Section 2637. 1 and all the information contained herein is accurate. UST Service Technician Signature � .cYGx4G�YLd- If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = international Code Council