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UNDERGROUND STORAGETANK 1 of 1) <br /> SPILL CONTAINER TESTING REPORT FORM (Page1,7 12 Month Test <br /> Repair Test <br /> Type of Action r Installation Test <br /> 1. FACILITY INFORMATION III III MIMI <br /> Date of Spill Container Test: <br /> 91212020 <br /> CERS ID <br /> 10165857 <br /> Business As . <br /> Business Name (Same as Facility Name or DBA-Doing Zip: <br /> 7-ELEVEN #19976 , MKT 2368 City: 95336 <br /> MANTECA <br /> Business Site Address <br /> 1399 N . MAIN ST. @ NORTHGATE TE <br /> IL UNDERGROUNDSTORAGETANKSERVICECH ion .) INFORMATION Phone # <br /> the Test (Print as shown on the ICC Certification .) (800) 800-4633 <br /> Name of UST Service Technician Performing ICC Certification Expiration Date <br /> Clint Fuhrman ICC Certification # 51212021 <br /> ContractorlTank Tester License # <br /> 9160945 <br /> Class A General Engineering 743160 hcable certifications. ) <br /> Spill Container Testing Training and Certifications (List app <br /> OPW - EVR Phase 1 904272 05123 <br /> 12021 Tanknology Certification - Level III Spill Container Testing Certification Exam 96740 051221202 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Manufacturer Guidelines: (Specify) <br /> Test Method Used : ecify) PEI RP 1200 <br /> r% Industry Code or Engineering Standard : (Sp <br /> Specify) # of Attached Pages <br /> Engineered Method : ( <br /> Attach the testing procedures and all documentation required to determine the results . <br /> Fill T4 : UNLEADED Fill T5: PREMIUM <br /> Tank ID: (By tank number, stored product) etc.) <br /> RUL PUL <br /> OPW OPW <br /> Non-Metallic � Non-Metallic <br /> (�' Non-Metallic <br /> Spill Container Manufacturer: f Isolation <br /> Non-Metallic J' isolation <br /> (" <br /> Isolation r Other <br /> Method of Cathodic Protection Other <br /> If' Isolation Other � Other <br /> (Specify in section V) (specify in section V) <br /> (Specify in section V) (Specify in section V) <br /> 12 12 <br /> Inside Diameter of Spill Container: (Inches) 16 <br /> 16 <br /> Depth of Spill Container: (inches) rys r No e <br /> (— Yes r No rYes r No <br /> Does the spill container have a 5 gallon ry Yes r No r Drain Valve <br /> r Drain Valve <br /> capacity? r Drain Valve Drain Valve Or Onsite Pump <br /> (` n <br /> (� Onsite Pump site Pump r Other <br /> r Onsite Pump (" Other <br /> Spill Container Empty ( " Other r Other Specify in section V) <br /> Method to Keep Sp (Specify in section V) <br /> (Specify in section V) <br /> Specify in section V) <br /> IV, SUMMARY OF TESTING RESULTS (Pass r: Fai <br /> .Pass Fail Pass �. Fail <br /> r,PaSS Fail <br /> Spill Container Test Results Ti V, COMMENTS <br /> so be provided here , <br /> explained in this section . Any additional comments may al <br /> All items marked failed above must be <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIANdCONDUCTING RTHISnss tIe 23 , division 3 , chapter 16 , sec <br /> Ill containers were tested in accordance with California Co <br /> 1 hereby certify that the spill <br /> 2637 .1 and all the information contained herein is accurate . <br /> UST Service Technician Signature <br /> �,✓�,�✓^ <br /> Of this page may be attached . <br /> If the facility has more components than this form accommodates , additional copies a tank, ICC=International Code Counc <br /> CERS=California Environmental Reporting System , ID=Identification , UST=Underground storage <br />