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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 E 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10402351 10/23/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> ARCO AM/PM#83230 <br /> Business Site Address city ZIP Code <br /> 1340 W. Colony Rd. Ripon 95366 <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 /> Guadalupe Sanchez (925)470- 0803 Ext. <br /> ContractodTank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1005444 5250451 4/8/2019 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> FFS EVR Phase I Systems# 1031393709 Expires: 3/4/2020 OPW# 0163755 Expires: 6/18/2019 <br /> III. SPILL CONTAINER TESTING INFORMATION14 14 0 f <br /> Test Method Used: <br /> ❑Manufacturer Guidelines:(Specify) <br /> E Industry Code or Engineering Standard:(Specify) PEI/RP1200-17 NOV 2 ti 2018 <br /> ❑Engineered Method:(Specify) F- ,IVIRONMF-_f\1Zr;; I-IFAI T� <br /> Attach the testing procedures and all documentation required to determine the results. t <br /> Tank ID:(By tank number,stored product,etc.) T1: 87 West T1: 87 East T2: 91 T3: Diesel <br /> Spill Container Manufacturer: Phil-Tite Phil-Tite Phil-Tite Phil-Tite <br /> ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> Method of Cathodic Protection E Isolation E Isolation E Isolation E Isolation <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V) <br /> Inside Diameter of Spill Container:(inches) <br /> 12" 12" 12" 12" <br /> Depth of Spill Container.(inches) 15 7/8" 14 3/4" 16" 16 1/4" <br /> Does the spill container have a 5 gallon capacity? E Yes ❑No E Yes ❑No E Yes ❑No E Yes ❑No <br /> E Drain Valve E Drain Valve E Drain Valve E Drain Valve <br /> Method to Keep Spill Container Empty ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑other ❑Other ❑other ❑Other <br /> (Specify in section V) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results E Pass ❑Fail E Pass ❑Fail E Pass ❑Fail ❑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 /> 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 Signal_ <br /> If the facility has more components than this form acco modates,additional copies of this page may be attached. <br /> rFRR=r_%J fnmia Frniimvrw-r*A Ponew innRuafnrr, in v kim%fimtinn I LCT a 1 InriPrrmw and cfrvarra tank Irr:=Inlc+"t*L awd rnria riv mr11 <br />