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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 N 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10166883 10/26/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> SUPER STORES INDUSTRIES <br /> Business Site Address City ZIP Code <br /> 16888 McKINLEY AVENUE LATHROP 95330 <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 /> Zane Nimmo (209 ) 744 - 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 04 - 1676 Ex . 3/31 / 19 8883064- UT 6/ 1 /2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 10009843708 Ex . 11 / 16/2018 <br /> OPW # 104-632 Ex . 3/ 14/2020 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method used : N Manufacturer Guidelines (Specify) : OPW PHASE I TRAINING - LAKE TEST <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify) : <br /> # of <br /> Attach the testing procedures and all documentation required to determine the results. Attached Pages <br /> TANK ID : (Bytanknumber, storedproduct, etc.) 1 - DSL EAST 2 - DSL WEST 3 - NEW OIL 4 - WASTE OIL <br /> Spill Container Manufacturer: OPW OPW EBW E B W <br /> Method of Cathodic Protection : ❑x Non- Metallic N Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑x Isolation ❑x Isolation <br /> ❑ Other (Specifyin V) ❑ Other (Specifyin V.) ❑ Other (Specifyin V) ❑ Other (Specifyin V) <br /> Inside Diameter of Spill Container: (Inches) 11 11 12 12 <br /> Depth of Spill Container: (Inches) 13 1 /2 13 13 12 1 /2 <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No [j] Yes ❑ No ❑x Yes ❑ No R Yes ❑ No <br /> Method to Keep Spill Container Empty: Drain Valve ❑x Drain Valve x Drain Valve ❑x Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specifyin V) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : zPass ❑IF Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass El Fail <br /> V. COMMENTS <br /> Any items marked "Fail" above must be explained in this section . Any additional comments may als` ovid Me e: <br /> ., v : t` <br /> NU 1, 4 2018 <br /> ENVIRONMENTAL HEALT <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TES `i'I W ENT IM <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 maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />