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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) Type of Action ❑x Installation Test ❑Repair Test ❑ 12 Month Test I. FACILITY INFORMATION CERS ID Date of Spill Container Test 2!712019 Business Name(Same as Facility Name or DBA-Doing Business As) Arco 7147 Business Site Address City ZIP Code 1206 E. March Lane Stockton 194901 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the/CC Certification) Phone# Alexander Tate (925) 551-7555 Contractor/Tank Tester license# ICC Certification# ICC Certification Expiration Dale 220793 8296693 3/4/2019 Spill Container Testing Training and Certifications(List applicable certifications) III. SPILL CONTAINER TESTING INFORMATION Test Method Used ❑Manufacturer Guidelines(Specify)• ❑Industry Code or Engineering Standard(Specify) ❑Engineered Method(Specify)' Attach the testing procedures and all documentation required to determine the results. #of Attached Pages TANK ID:(By tank number,stored product,etc.) 87 91 DSL Spill Container Manufacturer OPW Fill OPW Fill OPW Fill Method of Cathodic Protection [E Non-Metallic 0 Non-Metallic E Non-Metallic ❑Non-Metallic ❑Isolation ❑ Isolation ❑Isolation ❑Isolation ❑Other(Specify in V) ❑Other(Specify in V) ❑Other(Specify in V) ❑Other(Specify in V) Inside Diameter of Spill Container (Inches) 12 12 12 Depth of Spill Container:(Inches) 14 14 14 Does the spill container have a 5 gallon capacity? 9 Yes ❑No E]Yes ❑No F1 Yes ❑No ❑Yes ❑No Method to Keep Spill Container Empty: ❑Drain Valve ❑Drain Valve ❑Drain Valve ❑Drain Valve ❑x Onsite Pump 21 Onsite Pump El Onsite Pump ❑Onsite Pump ❑Other(Specify in V) ❑Other(Specify in V) I ❑Other(Specify in V) ❑Other(Specify in V) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results ❑x Pass ❑Fail ❑x Pass ❑Fa,17 z Pass ❑Fail ❑Pass ❑Fail V. COMMENTS Any items marked"Fail"above must be explained in this section. Any additional comments may also be provided here. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING hereby certify that the spill containers were tested in accordance with California Code of Regulations, Title 23, Division 3, Chapter 16,Section 2637.1 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accommodates,additional copies of this page may be attached. CERS=Caktorm Envronmental Reporting System,ID=ldentifigCon,UST=Underground Slorage Tank,ICC=International Code Council