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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Test ❑ Repair Test Z 12 Month Test I . FACILITY INFORMATION CERS ID Date of Spill Container Test 10181259 3/30/2020 Business Name (Same as Facility Name or DBA-Doing Business As) ATS SINCLAIR MINI MART Business Site Address City ZIP Code 7906 N . EL DORADO STREET STOCKTON , CA 95210 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # ZANE NIMMO (209 ) 744 -0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 04- 1676 Ex . 3/31 /22 8883064 - UT 6/2 /2021 Spill Container Testing Training and Certifications (List applicable certifications.) Franklin Fueling - EBW & Phil Tite # 10009843708 Ex . 11 /29/2020 OPW # 104- 632 Ex . 3/ 17/2022 III . SPILL CONTAINER TESTING INFORMATION Test Method Used : Zx Manufacturer Guidelines (Specify) : O P W PHASE I LAKE TESTING ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) 1 - 87 OCT 2 - 87 SLAVE 3 - 87 SYPHON 4 - 91 OCT Spill Container Manufacturer: O P W O P W O P W Method of Cathodic Protection : ❑x Non-Metallic ❑x Non-Metallic Zx Non-Metallic Z Non-Metallic ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation ❑ Other (Specify in V.) ❑ Other (Specify in V) ❑ Other (Specifyin V.) Z Other (Specify in V.) Inside Diameter of Spill Container: (Inches) 11 11 11 11 Depth of Spill Container: (Inches) 13 13 13 13 Does the spill container have a 5 gallon capacity? El Yes ❑ No ❑x Yes ❑ No F1 Yes ❑ No R Yes ❑ No Method to Keep Spill Container Empty: Zx Drain Valve ❑x Drain Valve ❑x Drain Valve Z Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump Z Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : Z Pass ❑ Fail ❑x Pass ❑ Fail X Pass Z Fail X Pass ❑ Fail V. COMMENTS Any items marked "Fail' above must be explained in this section . Any additional comments may also be provided here. ALL SPILLS CONTAINED IN FILL SUMPS W/ SENSORS ALL BUCKETS MEASURED 5 GALLONS VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING hereby certify that the spill containers were tested in accordance with California Code of Regulations , Title 23 , Division 3 , Chapter 16 , Section 2637 . 1 and all the information contained herein is accurate . UST Service Technician Signature ej If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council