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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 /> 10180717 4/11 /19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Fast & Easy Morada #60 ( Stockton ) <br /> Business Site Address City ZIP Code <br /> 10878 N Highway 99 Stockton 95212 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # <br /> Timothy Capehart (800 ) 339-9930 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 804904 8414476 3/3/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications) <br /> Opw 0167682 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> ❑x Industry Code or Engineering Standard (Specify) : PEI 1200 <br /> ❑ Engineered Method (Specify) : <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages 1 <br /> TANK ID : (By tank number, stored product, etc.) Premium- 1 Premium-2 Unleaded Diesel <br /> Spill Container Manufacturer: Opw Opw Opw Opw <br /> Method of Cathodic Protection : ❑x Non-Metallic ❑x Non-Metallic ❑x Non-Metallic X Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 11 .o" 11 . 0" 11 .0" 11 . 0" <br /> Depth of Spill Container: (Inches) 11 .o" 12. 5" 12.5" 12. 5" <br /> Does the spill container have a 5 gallon capacity? ❑ Yes El No ❑x Yes ❑ No ❑x Yes ❑ No N Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve x❑ Drain Valve 0 Drain Valve ❑x Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> EE <br /> Spill Container Test Results : ❑ Pass ❑x Fail Z Pass ElFail ❑x Pass ❑ Fail 0 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 /> The Premium #1 OPW fill spill bucket does not hold 5 gallons . Due to being a direct buried OPW spill bucket we will have to return and break concrete to <br /> make riser adjustments , replace and retest the spill bucket. Unleaded OPW fill spill bucket failed hydrostatic test due to leaking fill cap. Replaced cap and <br /> retested with pass . <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 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 = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br /> UNA08 www. unidocs.org 1 /1 - Rev. 06/14/18 <br />