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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 2112 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID — Date of Spill Container Test <br /> 10185183 07/09/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Aisle 1 #356 <br /> Business Site Address _ City ZIP Code <br /> 4219 Morada Ln Stockton 195212 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the /CC Certification.) one # <br /> Brian McPheely (408) 971 -2445 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8822062 11 /9/19 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 1014303708 <br /> Ill . SPILL CONTAINER TESTING INFORMATION <br />' Test Method Used : <br /> ❑ Manufacturer Gut delines (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 /> � —� � Philtite <br /> TANK ID . (By tank number, stored product, etc.) 1 " Regular 2 Prem 3 Diesel 4 <br /> Spill Container Manufacturer: Philtite Philtite Philt <br /> i - m _ . - <br /> Method of Cathodic Protection: <br /> ® Non-Metallic 0 Non-Metet <br /> allic ® Non-Metallic El Non-Metallic <br /> ❑ Isolation I ❑ 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) 12 112 — 12 <br /> Depth of Spill Container: (Inches) 15 112 15 15 <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 in V ) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ® Pass ❑ Fail 0 Pass ❑ Fair 0 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 /> VL ti. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 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 Tec/h�nicia_n,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 /> i <br />