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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 /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181487 05/22/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Shell #68153 <br /> Business Site Address City ZIP Code <br /> 2448 W. Kettleman Ln . Lodi 95242 <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 /> Brian McPheely (408) 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # ICG Certification Expiration Date <br /> 485184 18822062 111 /9/19 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 1014303708 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify): <br /> IZ Industry Code or Engineering Standard (Specify): PEI 1200 <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.) 1 Regular 2 Prem 3 Diesel 4 <br /> Spill Container Manufacturer: Philtite Philtite Philtite <br /> Method of Cathodic Protection: ® Non- Metallic ® Non-Metallic ® Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specifyin V) <br /> Inside Diameter of Spill Container: (Inches) 12 12 12 <br /> Depth of Spill Container: (Inches) 15 14 141 /4 <br /> Does the spill container have a 5 gallon capacity? © Yes ❑ No p Yes ❑ No © Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ® Drain Valve ® Drain Valve ® 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 : ® 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 /> Replaced the 87 Drain Valve and Gasket - Retested & Passed . <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 /> 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 = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />