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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action ElInstallation Test ❑ Repair Test ® 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10184365 12/10/ 18 <br /> Business Name (same as Facility Name or DBA-Doing Business As) <br /> Gas 4 Less <br /> Business Site Address City ZIP Code <br /> 3408 Manthey Rd . Stockton 95206 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Michael Briggs (408) 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # IGC Certification Expiration Date <br /> 485184 8033115 5/30/2019 <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 <br /> TANK ID : (By tante number, stored product, etc.) 1 Regular 2 Prem 3 4 <br /> Spill Container Manufacturer: PhikTite PhikTite <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 " <br /> Depth of Spill Container: (inches) 13 " 12 . 5" <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 ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> aaaaaaa <br /> V. COMMENTS <br /> Any items marked "Fall" above must be explained in this section. Any additional comments may also be provided here . <br /> Vl . 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 Cound <br />