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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Pagel of 1 ) <br /> Type of Action ❑ Installation Test ❑ Repair Test 0 12 Month Test <br /> I . FACILITY INFORMATION _ <br /> CERS ID Date of Spill Container Test <br /> 10181433 12/31 /19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> March Lane 76 <br /> Business Site Address City ZIP Code <br /> 2701 West March Lane Stockton 95219 <br /> Ila UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the /CC Certification.) IPhone # <br /> Brian McPheely (408) 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8822062 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Ae <br /> OPW # 104773 � <br /> F . F. # 1014303708 <br /> , r , r <br /> III, SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: 0 Manufacturer Guidelines (Specify): OPW _ <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 l <br /> TANK ID : (By tank number, stored product etc.) 1 Regular 2 Prem 3 Diesel € 4 <br /> Spill Container Manufacturer: J OPW J OPW J OPW q <br /> Method of Cathodic Protection: 0 Non-Metallic 0 Non-Metallic 0 Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specifyin V.) ❑ Other (Specify in V) ❑ Other (Specify in v.) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (inches) 12 12 12 <br /> Depth of Spill Container: (inches) 13 13 13 <br /> Does the spill container have a 5 gallon capacity? 2 Yes ❑ No ® Yes ❑ No © Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: 0 Drain Valve 0 Drain Valve 0 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 : 0 Pass ❑ Fail (a Pass El QJ 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 /> VL 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 , <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 may be attached. <br /> CERS = Calibmia Environmental Reporting System, ID = Identification, UST = Underground Storage TanK ICC = International Code Courxll <br />