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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 /> 10181463 3/6/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Village West Marina <br /> Business Site Address City ZIP Code <br /> 6649 Embarcadero Drive Stockton 95219 <br /> 11, UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Guadalupe Sanchez (925) 470 - 0803 Ext. <br /> Contractorfrank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1005444 5250451 le /2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW #0163755 Expires : 6/18/2019 FFS EVR Phase I Systems # 1031393709 Expires : 3/4/2020 <br /> Ill. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑ Manufacturer Guidelines: (Specify) <br /> ® Industry Code or Engineering Standard: (Specify) PEI/RP1200- 17 <br /> ❑ Engineered Method: (Specify) <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. 3 <br /> Tank ID: (By tank number, stored product, etc.) T1 : Diesel T2: 91 <br /> k <br /> Spill Container Manufacturer. OPW OPW <br /> I <br /> ❑ Nor-Metallic Nor-Metallic ❑ Nor-Metallic ❑ Nor-Metallic <br /> Method of Cathodic Protection ® Isolation ® Isolation ❑ Isolation ❑ isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify In section V.) (Specify in section V.) (Specify in section V.) (Specify In section V.) <br /> Inside Diameter of Spill Container: (inches) <br /> 11 " 11 " <br /> Depth of Spill Container. (inches) 13 3/4" 16 <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> ® Drain Valve ® Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> Method to Keep Spill Container Empty [IOnsite Pump ❑ Onsite Pump ElOnsite Pump [IOnsite Pump <br /> ❑ Other El Other <br /> ❑ Other ❑ Other <br /> (Specify in section V*) (Specf/y In section V.) (Specify in section V.) (Speciy /n section V.) <br /> IN. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail TO Pass ❑ Fall <br /> V. COMMENTS <br /> All 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, We 23, division 3, chapter 16, section <br /> 2637.1 and all the Information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more doirponents than this form accommo tes, addidonalp6ples of this page may be attached. <br /> MRC a r. t4*% „to FnvinvunonW RonnMrvs Cvafpm in = trimflfit tHm i LcT = I irvia,mnv uvi ammm hank irr. immuoinmt rexlo rM mral <br />