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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 Z 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10413073 3/30/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> COUNTRY MARKETPLACE <br /> Business Site Address City ZIP Code <br /> 1789 W . CHARTER WAY STOCKTON , CA 95206 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # <br /> ZANE NIMMO ( 209 ) 744 -0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 04 - 1676 Ex . 3/31 /22 8883064- UT 6/ 1 /2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 10009843708 Ex . 11 /29/2020 <br /> OPW # 104-632 Ex . 3/ 15/2022 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : z Manufacturer Guidelines (specify) : PHIL TITE PHASE I LAKE TESTING <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (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.) 87 OCTANE 91 OCTANE <br /> Spill Container Manufacturer: PHIL TITE PHIL TITE <br /> Method of Cathodic Protection : ❑x Non-Metallic ❑x 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) 12 12 <br /> Depth of Spill Container: (Inches) 14 1 /4 14 1 /2 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ❑ Drain Valve [jDrain Valve <br /> [:1Onsite Pump ElOnsite Pump ❑ Onsite Pump ElOnsite Pump <br /> ElOther (Specify L❑ Other (Specify in V.) ElOther (Specify in V.) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : 0 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 /> ANI\ ZON <br /> CNVIRONMEITAL HEALTF <br /> nrO!.�, RTMFNT <br /> Vl . 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 = Identification, UST = Underground Storage Tank, ICC = International Code Counal <br />