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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM <br /> Type of Action ❑ Installation Test ❑ Repair Test 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID [Dtae of Spill Container Test <br /> 10182167 /14/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> VALLEY PACIFIC HWY 99 CARDLOCK <br /> Business Site Address City ZIP Code <br /> 3550 S HWY 99 Stockton 95215 <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 /> Garrett Warren (916) 991 - 1100 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> CSLB#803616 8185019 9-20-2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW EVR 101018 exp. 6-5-2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method <br /> Used: E]Manufacturer Guidelines: <br /> (Specify) <br /> 0 Industry Code or Engineering Standard: RP 1200 <br /> (Specify) <br /> ❑ Engineered Method: <br /> (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.) T1: Unleaded T2: DFR <br /> Spill Container Manufacturer: OPW OPW <br /> M Non-Metallic M Non-Metallic ❑ Non-Metallic ❑Non-Metallic <br /> Method of Cathodic Protection M Isolation 0 Isolation ❑ Isolation ❑Isolation <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container: (Inches) 1 ill 1 1 11 <br /> Depth of Spill Container: (Inches) 12.25" 13.50" <br /> Does the spill container have a 5 gallon I I Yes ❑ No El Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No <br /> capacity? <br /> M Drain Valve 0 Drain Valve ❑ Drain Valve ❑Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump ❑Onsite Pump ❑ Onsite Pump ❑Onsite Pump <br /> ❑ Other ❑Other ❑ Other ❑Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results M Pass ❑ Fail 11 M Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> All 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,chapter 16,section <br /> 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 />