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20200037 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Test ❑Repair Test Mx 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181263 1/22/2020 <br /> Business Name(Same as FacrL7y Name or DBA-Doing Business As) <br /> Arco 6080 <br /> Business Site Address City ZIP Code <br /> 85 E Louise Ave Lathrop 195330 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certirication) Phone# <br /> Matthew Campbell (925) 551-7555 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Dale <br /> 220793 1 8716847 4/8/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications) <br /> OPW Tech Cert# 0165585 Exp. 101312021 <br /> Ili. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used Manufacturer Guidelines(Specify) <br /> Hydrostatic, OPW, Tape Measure <br /> ❑Industry Code or Engineering Slandard(Specify) <br /> ❑Engineered Method(Specify) <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> TANK ID:(By tank number,stored product,etc) 87 A Fill T1 87 B Fill T1 91 Fill T2 DSL Fill T3 <br /> Spill Container Manufacturer OPW OPW OPW OPW <br /> Method of Cathodic Protection Q Non-Metallic ❑x Non-Melalltc ❑x Non-Metallic Q Non-Melallic <br /> ❑Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(Specify in v) ❑Other(Spocify in, i ❑Other(Specify in V: ❑Other jS E.cify in V) <br /> Inside Diameter of Spill Container (Inches) 12 12 12 12 <br /> Depth of Spill Container (Inches) 14 14 14 14 <br /> Does the spill container have a 5 gallon capacity? (]Yes ❑No [j]Yes ❑No ❑Yes ❑No I]Yes ❑No <br /> Method to Keep Spill Container Empty ❑Q Drain Valve x❑Drain Valve Q Drain Valve ❑x Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in v) I ❑Other(Speufy in v ❑Other(Specify in v) ❑Other rSperdy in v) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ❑x Pass ❑Fail I E)Pass ❑Fa:lx❑Pass ❑Fail 21 Pass ❑Fail <br /> V. COMMENTS <br /> Any items marked"Fail"above must be explained in this section Any additional comment;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 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=Idem cordon.UST=Underground Storage Tank.ICC=fntematonal Code Council <br />