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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 ® 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10422475 07/02/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Yosemite Avenue ARCO Am Pm <br /> Business Site Address City ZIP Coe <br /> d <br /> 1711 E . Yosemite Ave . Manteca 95336 <br /> 11, UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Cert cation.) Phone # <br /> Guadalupe Sanchez (925) 470 - 0803 Ext. <br /> Contractorfrank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1005444 5250451 04/05/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> FFS EVR Phase I Systes # 1031393709 Expires: 03/04/2022 OPW # 0163755 0163755 Expires : 06/07/2021 <br /> m <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑ Manufacturer Guidelines: (Specify) <br /> ® Industry Code or Engineering Standard: (Specify) PEI/RP1200- 17 <br /> ❑ Engineered Method: (Specify) <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> Tank ID: (By tank number, stored product, etc.) T1 : 87 Master T2 : 87 Slave T3 : 91 <br /> Spill Container Manufacturer. OPW OPW OPW <br /> ® Non-Metallic ® Non-Metallic ® Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify In section V.) <br /> 11 <br /> " <br /> Inside Diameter of Spill Container (Inches) 11 " 11 " <br /> Depth of Spill Container: (inches) 12 12 12" <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No <br /> ® Drain Valve ® Drain Valve ® Drain Valve ❑ Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> All Items marked 7611" above must be explained in this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 23, division 3, chapter 16, section <br /> 2637.1 and all the Information contained herein is accurate. <br /> UST Service Technician Signature <br /> E <br /> If the facility has more components than this form accom dates, addit/ net copies of this page may be attached <br /> rFRR = rafifr�mia Fnvirrv,rnnrdal RorvuHm Rvdwm In o tao%ntNirAHm I IRT o i Irviammi and ¢trvarn tank Ir r o Irdorrndinnai rrvin rry mcii <br />