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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 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181441 1 /23/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> RIVER POINT LANDING <br /> Business Site Address City ZIP Code <br /> 4950 BUCKLEY COVE WAY STOCKTON , CA 95219 <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 /> EDWARD STEANS (209) 744- 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 9/30/20 8883080 - UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 1009893708 Ex. 11 /29/2020 <br /> OPW # 104-635 Ex . 3/14/2020 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : x❑ Manufacturer Guidelines (Specify) : LAKE TEST <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 /> jTANK ID : (By tank number, storedproduct, etc.) 89 DIESEL <br /> i <br /> Spill Container Manufacturer: OPW OPW <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) 11 11 <br /> Depth of Spill Container: (Inches) 14112 121 /2 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑x Yes ❑ No E] Yes ❑ No El Yes ElNo <br /> Method to Keep Spill Container Empty: 0 Drain Valve ❑x Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ElOther (Specify in V.) ElOther (Specify in V.) ElOther (Specify in V.) El Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : IF 0 Pass ❑ Fail Q Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" above must be explained in this section. Any additional comme fiy alio be ptdvided hefei r =° <br /> a <br /> ENVIM _ ° 41 /AL IE:A T <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTI G THI $ 799"M <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 Signaturey <br /> "e facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Coundl <br />