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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 ❑Q 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180661 12/ 12/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> ONE STOP MARKET <br /> Business Site Address City ZIP Code <br /> 1151 W . LOUISE AVENUE MANTECA , CA 95336 <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 /> ZANE NIMMO (209 ) 744-0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date i <br /> 04- 1676 Ex . 3/31 /22 8883064 - UT 6/ 1 /2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 10009843708 Ex . 11 /29/2020 <br /> OPW # 104-632 Ex. 3/ 14/2020 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify) : O P W PHASE I LAKE TESTING <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 OCTANE DIESEL 91 OCTANE <br /> Spill Container Manufacturer: O P W O P W O P W <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 (Specifyin V.) ❑ Other (Specify in V) <br /> Inside Diameter of Spill Container: (Inches) 11 1 /2 11 1 /2 11 1 /2 <br /> Depth of Spill Container: (Inches) 13 13 1 /2 13 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑x Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ❑x Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) ❑ Other (specify in V.) ❑ Other (Specifyin V) ❑ Other (Specify in V.) <br /> IV . SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ZPass ❑ Fail ZPass ❑ Fail ❑x Pass El Fail El Pass El Fail <br /> V. COMMENTS <br /> Any items marked "Fail' above must be explained in this section. Any additional comments may a&ojejQwvjfedh „ r h” Li <br /> ALL FIVE GALLONS + n LMj <br /> JAN J 7 2020 <br /> ENVIRONMENTAL HEALTP <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THISL - <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 = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />