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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 0 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10726990 8/25/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Pilot 1017 Lathrop <br /> Business Site Address City ZIP Code <br /> 345 Roth Rd . French Camp 95231 <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 /> Jose Ochoa ( 888 ) 972 -7581 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 804431 A , 13 HAZ 8004551 - UT 12/27/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW Cert# 100826 <br /> Expiration : 12-28 -2021 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : 0 Manufacturer Guidelines (Specify) : 'rape Measurer - Stop Watch <br /> ❑x Industry Code or Engineering Standard (Specify) : PEI 1200 <br /> ❑ Engineered Method (Specify): <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages5 <br /> TANK ID : (By tank number, stored product, etc.) T- 1 Unleaded T-2 Premium <br /> Spill Container Manufacturer: OPW OPW <br /> Method of Cathodic Protection : 0 Non- Metallic ❑x Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑x Isolation 9 Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V) ❑ Other (Specifyin V) <br /> Inside Diameter of Spill Container: (Inches) 12 12 if <br /> Depth of Spill Container: (Inches) 16 16 It <br /> Does the spill container have a 5 gallon capacity? I] Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve 0 Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specifyin V) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : 9 Pass ❑ Fail ❑x Pass ❑ Fail ❑ 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 /t <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 />