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�iiiiiiiii: NINE <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Test ❑ Repair Test Z 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181669 4/22/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> QUICK SHOP # 1 <br /> Business Site Address City ZIP Code <br /> 2072 W. YOSEMITE MANTECA 95337 <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 /> Edward Stearns (209) 744-0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 9/30/20 8883080- UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 1009893708 Ex . 11 /29/2020 <br /> OPW # 104 -635 Ex. 3/14/2020 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify) : LAKE TEST <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify): <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages <br /> TANK ID : (By tank number, stored product, etc.) DIESEL <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection : ❑x Non-Metallic El Non-Metallic ❑x 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 11 11 <br /> Depth of Spill Container: (Inches) 13 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: rZ Drain ValveElDrain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ElOnsite Pump ElOnsite Pump E] Onsite Pump <br /> ElOther (Specifyin V.) ❑ Other (Specifyin v) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ❑Q Pass ❑ Fail ❑ Pass ❑ Fail ❑ 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 /> Follow up testing to repairs on Failed test Dec 2018 <br /> WWME D <br /> R E E IVP <br /> J I I N ) 7 20119 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIA 1ilffis[T T <br /> I hereby certify that the spill containers were tested in accordance with California Title 23 , Division 3 , <br /> Chapter 16, Section 2637 . 1 and all the information contained herein is accurate . <br /> UST Service Technician Signature , J <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 /> I <br />