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i <br /> 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 /> 10182155 5/28/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> SYSTEM TRANSPORT <br /> Business Site Address City ZIP Code <br /> 707 ROTH ROAD FRENCH CAMP , CA 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 /> FELIX RAMIREZ ( 209 ) 744 - 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 0 & 1740 5-31 -20 8883072- UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications) <br /> Franklin Fueling - EBW & Phil Tile # 1009883708 11 /29/20 <br /> OPW # 104634 3A4-20 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify): <br /> ❑x Industry Code or Engineering Standard (Specify): LAKE TEST / PEI 100 <br /> ❑ Engineered Method (Specify): <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> TANK ID : (By tank number, stored product, etc) DIESEL <br /> Spill Container Manufacturer: EMCO <br /> Method of Cathodic Protection: 0 Non-Metallic ❑ Non-Metallic ❑ 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) 11 <br /> Depth of Spill Container: (Inches) 13 <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: 0 Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) <br /> E] Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : zPass El FF Fail I 11❑ Pass ❑ Fail El Pass El El Pass El 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 /> 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 = Identficaton, UST = Underground Storage Tank, ICC = International Code Council <br />