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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Pagel of 1) <br /> Type of Action ❑ Installation Test ❑ Repair Test ❑x 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180913 1/8/20 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> ERNIE'S GENERAL STORE <br /> Business Site Address City ZIP Code <br /> 4407 E WATERLOO RD STOCKTON, CA 95215 <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.) 87 91 DIESEL <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: Nx Non-Metallic I]Non-Metallic Z Non-Metallic ❑Non-Metallic <br /> ❑ Isolation ❑Isolation ❑Isolation N Isolation <br /> N Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) N Other(Specify in V.) <br /> Inside Diameter of Spill Container:(Inches) 11 11 11 <br /> Depth of Spill Container:(Inches) 14 14 14 <br /> Does the spill container have a 5 gallon capacity? FAI Yes ❑No ❑x Yes ❑ No 9 Yes ❑No ❑Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve x❑Drain Valve ❑x Drain Valve ❑Drain Valve <br /> N Onsite Pump ❑Onsite Pump ❑Onsite Pump N Onsite Pump <br /> ❑Other(Specify LK.)JI ❑Other(Specify in V.) N Other(Specify in V) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑x Pass El=Fail Pass ❑Fail Pass NFail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked"Fail"above must be explained in this section. Any additional comments may a/srrj,provided here ,,, . ; <br /> J A 1 1 5 <br /> ENVIRONMENTAL HEALT <br /> -)EPARTMENT <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 n; <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 />