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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 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 /> 10182107 6/11/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Quick Stop #124 <br /> Business Site Address City ZIP Code <br /> 505 N. Main St Manteca 195336 <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 /> Curtis Carpenter 1 (916) 372-1885 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 617238 1 8167865 5/14/2022 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW, Phil-Tite <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> #of <br /> Attach the testing procedures and all documentation required to determine the results. Attached Pages <br /> TANK ID:(By tank number,stored product,etc.) 1-87 2-89 3-91 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> ❑X Isolation x❑Isolation ❑x 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) 11.5 11.5 11.5 <br /> Depth of Spill Container:(Inches) 14.5 14.5 13 <br /> Does the spill container have a 5 gallon capacity? 2 Yes ❑No Fil Yes ❑No M Yes ❑ No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ❑Drain Valve ❑Drain Valve ❑Drain Valve ❑Drain Valve <br /> Z Onsite Pump 0 Onsite Pump I]Onsite Pump ❑Onsite Pump <br /> ❑Other(Specifyi V) ❑Other(Specify in V.) ❑Other(Specify in V) ❑Other(Specify in V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: 0 Pass ❑ Fail 9 Pass ❑Fail N Pass ❑ Fail ❑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 /> 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 /> /f 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 />