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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Pagel of 1) <br /> Type of Action ❑ Installation Test ❑Repair Test ❑x 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181565 4/6/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Pershing Gas 4 Less <br /> Business Site Address City ZIP Code <br /> 4445 N Pershing Rd. Stockton 195702 <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 /> Frank Amestoy (800) 339-9930 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 804904 8374998 10/29/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW 0175366 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines(Specify): <br /> ❑X Industry Code or Engineering Standard(Specify): PEI 1200 <br /> ❑Engineered Method(Specify): <br /> #of <br /> Attach the testing procedures and all documentation required to determine the results. Attached Pages 1 <br /> TANK ID:(By tank number,stored product,etc.) 91 Diesel 87 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic 0 Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container:(Inches) 12.00" 12.00" 12.00" <br /> Depth of Spill Container:(Inches) 15.00" 15.00" 15.00" <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑No ❑x Yes ❑No E Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve (]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(Specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑x Pass ❑Fail ❑x Pass ❑Fail ❑x Pass ❑ Faiilj ❑ 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 /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 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=Califomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br /> UN-108 www.unidocs.org 1/1 -Rev.06/14/18 <br />