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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 /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 5/ 18/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Super Center <br /> Business Site Address City ZIP Code <br /> 701 E Charter Way Stockton 95206 <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 /> Chris Adams (209 ) 461 -6337 <br /> Contractor / 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 : ❑x Manufacturer Guidelines (Specify): Hydrostatic <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 <br /> Spill Container Manufacturer: OPW OPW <br /> Method of Cathodic Protection: I] Non-Metallic El NonWetallic ❑ Non-Metallic ❑ NonWetallic <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) <br /> 1 <br /> Depth of Spill Container: (Inches) 14 14 " <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No 2 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: [E Drain Valve ❑x Drain Valve ❑ Drain Valve ❑ 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 /> Spill Container Test Results: ❑x Pass ❑ Fail tg Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS . <br /> Any items marked 'Fail' above must be explained in this section. Any additional comments a also be pravlded harp <br /> ",4 A y � <br /> i <br /> VI CERTIFICATION BY <br /> UST SERVICE TECHNICIAN CONDUCTING THI$ TESTING <br /> I hereby certify that the spill containers were tested in accordance with California Code of RegulaliorisItle it3 , Division 3, <br /> Chapter 16 , Section 2637.1 and all the Information contained herein is accurate. <br /> UST Service Technician Signature /�ZQX�i <br /> If the facility has more components than tlWs form accommodates, additional copies of this page may be attached. <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />