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r Y <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page i of q <br /> Type of Action 21 Installation Test ❑ Repair Test <br /> I . FACILITY INFORMATION 2 _ F � <br /> CERS ID Date of Spill Contalnb Te§t` tis ' " <br /> 5/20/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Super Center Mart <br /> Business Site Address City ZIP Code <br /> 701 E Charter Way Stockton 95206 <br /> ll . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Chris Adams ( 209 ) 461 -6337 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1001331 A- HAZ 8230218 9/ 1 /2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW 100305 Exp : 5/23/2021 <br /> III . SPILL' CONTAINER TESTING INFORMATION <br /> Test Method Used: R Manufacturer Guidelines (specify): Hydrostatic <br /> ❑ Industry Code or Engineering Standard (Specify): <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.) 87 91 <br /> Spill Container Manufacturer: OPW OPW <br /> Method of Cathodic Protection: ❑x Non-Metallic Z Non-Metallic ❑ Non-Metallic ❑ 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 /> t <br /> j Inside Diameter of Spill Container: (inches) <br /> Depth of Spill Container: (inches) 1515 �� <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No (] Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: 0 Drain Valve 0 Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specily in V.) ❑ Other_ (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> IV, SUMMARY OF TESTING RESULTS ` <br /> Spill Container Test Results: N Pass ❑ Fail 21 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass -[]-Fail <br /> ff <br /> V. COMMENTS <br /> Any items marked Fail' above must be explained in this section. Any additional comments may also be provided here. <br /> VI . CERTIFICATION BY USTSERVICE 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, <br /> Chapter 16 , Section 2637. 1 and all the information contained herein is accurate. <br /> UST Service Technician Signature C4 <br /> If the facility has more components tban this form accommodates, additional copies of this page may be attached. <br /> International Code Council= California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = <br />