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UNDERGROUNDSTORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM ( Page 1 of 1 ) <br /> Type of Action ❑ Installation Test ❑ Repair Test 9 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 2 / 14/ 19 <br /> Business Name (Same as Facility Name or DBA -Doing Business As) <br /> AG SPANOS JET CENTER <br /> Business Site Address City ZIP Code <br /> 4800 S . AIRPORT WAY STOCKTON , CA 95208 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the /CC Certification.) Phone # <br /> EDWARD STEARNS (209 ) 744 - 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 9/30/20 888308 - UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 1009893708 Ex . 11 /29/202 <br /> OPW #104- 635 Ex . 3/ 14/2020 <br /> III . SPILL CONTAINER STING INFORMATION <br /> Test Method Used : E 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 d termine the results. # of Attached Pages <br /> TANK ID : (By tank number, stored product, etc.) JET- 1 JET-2 JET- 3 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection : ❑x Non -Metallic Non - Metallic ❑x Non - Metallic <br /> r[I❑ Isolation Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) Other (Specify in V) ❑ Other (Specify in V) <br /> Inside Diameter of Spill Container: (Inches) 11 11 11 <br /> Depth of Spill Container: (Inches) 13 3 12 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No Yes ❑ No ❑x Yes ❑ No <br /> Method to Keep Spill Container Empty : ❑x Drain Valve 7DrainalveJV ) <br /> ❑x Drain Valve =Valve <br /> ❑ Onsite Pump Pump ❑ Onsite Pump Other (Specify in V) pecify i ❑ Other (Specify in V) <br /> IV. SUMMARY OFT STING RESULTS <br /> Spill Container Test Results : ® Pass ❑ Fail Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass <br /> Fail <br /> VM <br /> V. COM ENTS <br /> Any items marked `Fail" above must be explained in this section. Any a ditional comments may also be provided here. <br /> VI . 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 s accurate . <br /> UST Service Technician Signature <br /> If the facility has more components than this form accommodates, additional opies of thispage maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identification , UST = Underground Sto ge Tank, ICC = International Code Council <br />