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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 0 12 Month Test <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180839 8/29/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> EL DORADO FOOD MART <br /> Business Site Address City ZIP Code <br /> 1901 S EL DORADO ST 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 /> Edward Stearns (209 ) 744- 0112 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 9/30/20 888308MT 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 /> 111 . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : Rx 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 <br /> Spill Container Manufacturer: OPW OPW <br /> Method of Cathodic Protection : ❑x Non- Metallic N Non-Metallic ❑x 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 /> Inside Diameter of Spill Container: (Inches) 11 11 <br /> Depth of Spill Container: (Inches) 13 13 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: Rx Drain Valve N Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) l ❑ 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 ❑ Pass 9 Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail' above must be explained in this section . Any additional comments may also be provided here. , <br /> 91 BUCKET FAILED LAKE TEST WILL NEED REPAIRS ' <br /> pe <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING5, [ NG ' ' <br /> hereby certify that the spill containers were tested in accordance with California Code of Regulations ,' Title 23, Division 31 <br /> Chapter 16 , Section 2637. 1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />