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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 /> 10181399 05/31119 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Grantline Shell <br /> Business Site Address a City ZIP Code <br /> 2375 W. Grant Line Tracy 95376 <br /> 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the 10C Certification.) Phone # <br /> Kristopher Bell (408) 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 18833000 7/22/20 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 1002583708 <br /> 111. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> ® 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 1 <br /> TANK ID: (By tank number, stored product, etc.) 1 Regular 2 Plus 3 Prem 4 Diesel <br /> Spill Container Manufacturer: PhikTite Phil-Tite Phil -Tite Phil-Tite <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 (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 13" 13" 13" 13" <br /> Depth of Spill Container: (inches) 13" 13" 13" 13" <br /> Does the spill container have a 5 gallon capacity? ❑ Yes ® No ❑ 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 ;n V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> N. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ❑ Pass ® Fail ❑ Pass ® Fail ® Pass ❑ Fail 1 ❑ 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 /> i <br /> 87 , 89 , and Diesel Spill Buckets don't hold 5 gallons , <br /> i <br /> i <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 = Cafrfomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br /> i <br />