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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Test ❑ Repair Test M 12 Month Test I . FACILITY INFORMATION CERS ID Date of Spill Container Test 10182099 2/25/2020 Business Name (Same as Facility Name or DBA-Doing Business As) SYNERGY - CENTRAL GAS MAIN Business Site Address City ZIP Code 3440 E MAIN STREET STOCKTON , CA 95205 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # DAVID WINKLER ( 209 ) 744 - 0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 0 & 1739 Ex . 3/31 /20 8883059 - UT 1 /29/2020 Spill Container Testing Training and Certifications (List applicable certifications.) Franklin Fueling - EBW & Phil Tite # 10009853708 Ex . 11 /29/20 OPW # 104-633 Ex . 3/ 14/2020 III . SPILL CONTAINER TESTING INFORMATION Test Method Used : ❑x Manufacturer Guidelines (Specify) : WATER TEST ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) 87 91 DSL Spill Container Manufacturer: OPW OPW OPW Method of Cathodic Protection : 0 Non-Metallic N Non-Metallic ❑x Non-Metallic ❑ Non-Metallic ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation ❑ Other (Specifyin V.) ❑ Other (Specifyin V) ❑ Other (Specifyin V.) rEl Other (Specifyin V.) Inside Diameter of Spill Container: (Inches) 12 12 12 Depth of Spill Container: (Inches) 14 14 14 Does the spill container have a 5 gallon capacity? ❑x Yes El No R Yes El No ❑x Yes El No YesElNo Method to Keep Spill Container Empty: XDrain Valve MDrain Valve XDrain Valve Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : 9 Pass ❑ Fail ❑x Pass El- all ❑x Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail' above must be explained in this section. Any additional comments may also be provided here . VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations , Title 23 , Division 3 , Chapter 16 , Section 2637 . 1 and all the information contained herein is accurate . UST Service Technician Signature W If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council