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UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Test Test 12 Month Test Type of Action • Installation M Repair 0 <br />I. FACILITY INFORMATION <br />CERS ID Date of Spill Container Test <br />3/12/2020 <br />Business Name (Same as Facility Name or DBA -Doing Business As.) <br />Shell 1-5 <br />Business Site Address <br />717 W Eighth St. <br />City <br />Stockton <br />ZIP Code <br />95206 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) <br />Jeff Conger <br />Phone # <br />(707) 386 - 7573 Ext. <br />Contractor/Tank Tester License # <br />90-1116 <br />ICC Certification # <br />1081782 <br />ICC Certification Expiration Date <br />11/24/21 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />OPW #104789 Exp 4/1/2021 FFS EVR Phase 1- VR101 (Phil-tite) #1020003708 Exp 4/10/2021 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />(Specify) Phit-tite installation guide 0 Manufacturer Guidelines: <br />Standard: (Specify) PEI Industry Code or Engineering <br />Engineered Method: (Specify) <br />Attach the testing procedures and all documentation required to determine the results. <br /># of Attached Pages <br />Tank ID: (By tank number, stored product, etc.) #1-Regular #2-Premium #3-Diesel <br />Spill Container Manufacturer: Philtite Philtite Philtite <br />Method of Cathodic Protection <br />n Non-Metallic Non-Metallic <br />V.) <br />n Non -Metallic <br />in section V.) <br />• Non-Metallic <br />Isolation <br />Other <br />in section V.) (Specify <br />Isolation Isolation Isolation • <br />Other M Other Other III <br />(Specify in section V.) (Specify in section (Specify <br />Inside Diameter of Spill Container: (Inches) 11 11 11 <br />Depth of Spill Container: (Inches) 14 1/4 15 1/2 16 1/4 <br />Does the spill container have a 5 gallon capacity? No 0 Yes • No 0 Yes M No Yes • Yes • No <br />Method to Keep Spill Container Empty <br />n Drain Valve n Drain Valve <br />Pump <br />V.) <br />Drain Valve <br />Pump <br />in section V.) <br />M Drain Valve <br />Onsite Pump <br />Other <br />in section V.) (Specify <br />Onsite Pump Onsite U Onsite M <br />IN Other II Other MI Other III <br />(Specify in section V.) (Specify in section (Specify <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results Pass • Fail Pass U Fail 0 Pass MI Fail M Pass • Fail <br />V. COMMENTS <br />All items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. <br />Inspector Paul Nso on site. All spill buckets now hold at least the required 5 gals. <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, chapter 16, section <br />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