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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) Type of Action ❑ Installation Test ❑ Repair Test E 12 Month Test I. FACILITY INFORMATION CERS ID Date of Spill Container Test 10181019 11/01/2019 Business Name(Same as Facility Name or DBA-Doing Business As.) Tracy Market Business Site Address City ZIP Code 15 E. Grant Line Rd. Tracy, CA 95376 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# Marco Alejos (888) 500 - 2435 Ext.2 ContractoriTank Tester License# ICC Certification# ICC Certification Expiration Date 958763 8415074 04/27/2021 Spill Container Testing Training and Certifications(List applicable certifications.) OPW Phase 1 EVR#0177295 exp. 03/04/2021 III. SPILL CONTAINER TESTING INFORMATION Test Method Used: ❑ Manufacturer Guidelines:(Specify) E Industry Code or Engineering Standard: (Specify) Hydrostatic One Hour Lake Test ❑ Engineered Method: (Specify) Attach the testing procedures and all documentation required to determine the results. #of Attached Pages Tank ID:(By tank number,stored product,etc.) Regular Regular Syphon Super Spill Container Manufacturer: OPW OPW OPW E Non-Metallic E Non-Metallic E Non-Metallic Method of Cathodic Protection ❑ Isolation ❑ Isolation ❑ Isolation ❑Other ❑Other ❑ Other (Specify in section V.) (Specify in section V.) (Specify in section V.) Inside Diameter of Spill Container:(Inches) 12 12 12 Depth of Spill Container:(Inches) 14 14 14 Does the spill container have a 5 gallon capacity? E Yes ❑ No E Yes ❑ No E Yes ❑ No E Drain Valve E Drain Valve E Drain Valve Method to Keep Spill Container Empty ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Other ❑ Other ❑Other (Specify in section V) (Specify in section V.) (Specify in section V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results E Pass ❑ Fail 1 E Pass ❑ Fail E Pass ❑ Fail V. COMMENTS All items marked"Fail"above must be explained in this section.Any additional comments may also be provided here. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations,title 23,division 3,chapter 16,section 2637.1 and all the information contained her i ccurate. UST Service Technician Signature If the facility has more components than thWYVfffFa6dommodates,additional copies of this page maybe attached. CERS=California Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council