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01 <br /> MINIMIZE all liii:ii <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Test ❑ Repair Test ❑x 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10157477 09/28/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Shell Oil Products <br /> Business Site Address City ZIP Code <br /> 3515 Navy Dr. Stockton 95203 <br /> I1 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Jarrett Flewellyn (714) 560-8222 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 588098 8028164 2/20/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> Hydrostatic <br /> 9 Industry Code or Engineering Standard (Specify) : PEI RP1200 <br /> ❑ Engineered Method (Specify) : <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages <br /> 1 <br /> TANK ID : (By tank number, stored product, etc.) Slop Tank <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection : ❑x Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non- Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) <br /> Inside Diameter of Spill Container: (Inches) 11 . 00" <br /> Depth of Spill Container: (Inches) 10 . 75" <br /> Does the spill container have a 5 gallon capacity? ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in K.)jj ❑ Other (Specify in V) ❑ Other (Specifyin V.) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : El Pass 9 Fail ❑ Pass ❑ Fail Ir ❑ 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 /> Spill bucket does not hold a full five gallons . Spill bucket is an automatic failure . <br /> Check If Action Item (s) Are Present <br /> VI . 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 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 Council <br />