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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 9 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 1 /3 /2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Colonial Energy <br /> Business Site Address City ZIP Code <br /> 192 Lathrop Road Lathrop 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 /> Anthony Reyes ( 916 ) 372 - 1885 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 617238 8293772 9/ 16/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) _ <br /> C r E <br /> OPW Tech# 103920 , PhikTite Tech# 1003213709 yl <br /> Y . � <br /> Vz <br /> III . SPILL CONTAINER TESTING INFORMATION 0 2019 <br /> Test Method Used : 0 Manufacturer Guidelines (Specify) : Lake Test <br /> ❑ Industry Code or Engineering Standard (Specify) : EN\J° I 0/ NNiEN AI_ <br /> R Engineered Method (Specify) : <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> TANK ID : (By tank number, stored product, etc.) 87 Master 87 Slave 91 Gasoline Diesel <br /> Spill Container Manufacturer: OPW OPW OPW OPW <br /> Method of Cathodic Protection : ❑ Non-Metallic R Non-Metallic ❑ Non-Metallic R Non-Metallic <br /> ❑x Isolation X Isolation ❑x Isolation 0 Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V) R Other (Specify in V.) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 11 . 5 11 . 5 11 . 5 11 . 5 <br /> Depth of Spill Container: (Inches) 15 15 15 15 <br /> Does the spill container have a 5 gallon capacity? R Yes ❑ No R Yes R No 0 Yes ❑ No R Yes R No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve X Drain Valve ix Drain Valve ❑x Drain Valve <br /> R Onsite Pump ❑ Onsite Pump R Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : 1E Pass ❑ Fail ❑x Pass ❑ Fail ❑x Pass ❑ Fail ❑x Pass R 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 /> 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 tha/n I 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 />