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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Test ❑ Repair Test Q 12 Month Test 1 . FACILITY INFORMATION CERS ID Date of Spill Container Test 10180717 4/11 /19 Business Name (Same as Facility Name or DBA-Doing Business As) Fast & Easy Morada #60 ( Stockton ) Business Site Address City ZIP Code 10878 N Highway 99 Stockton 95212 Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # Timothy Capehart (800 ) 339- 9930 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 804904 8414476 3/3/2020 Spill Container Testing Training and Certifications (List applicable certifications.) Opw 0167682 8/19/20 III . SPILL CONTAINER TESTING INFORMATION Test Method Used : ❑ Manufacturer Guidelines (Specify) : ❑x Industry Code or Engineering Standard (Specify) : PEI 1200 ❑ 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.) Premium- 1 Premium-2 Unleaded Diesel Spill Container Manufacturer: Opw Opw Opw Opw Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic 0 Non-Metallic g Non-Metallic ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specifyin V.) ❑ Other (Specify in V.) Inside Diameter of Spill Container: (Inches) 11 .0" 11 .0" 11 .01, Depth of Spill Container: (Inches) 11 .0" 12. 5" 12.5 12. 5 Does the spill container have a 5 gallon capacity? ❑ Yes ❑x No ❑x Yes ❑ No 0 Yes ❑ No X Yes ❑ No Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ❑x Drain Valve ❑x Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Other (Specifyin V) ❑ Other (Specify in V) ❑ Other (Specify in V) ❑ Other (Specify in V) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : ❑ Pass Fail Q Pass ❑ Fail 0 Pass ❑ Fail ❑Q Pass ❑ Fail j V. COMMENTS Any items marked "Fail" above must be explained in this section. Any additional comments may also be provided here . j 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 i make riser adjustments and replace the spill bucket and retest. Unleaded fill spill bucket failed hydrostatic test due to leaking fill cap retested with pass. E VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING 1 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 = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council UN-108 www. unidocs.org 1 /1 - Rev. 06/14/18 I