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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Test ❑ Repair Test M 12 Month Test I . FACILITY INFORMATION CERS ID Date of Spill Container Test 10182111 2/ 13/2019 Business Name (Same as Facility Name or DBA-Doing Business As) ELDORADO FOOD MART Business Site Address City ZIP Code 2320 N . EL DORADO STREET STOCKTON , CA 95204 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # ZANE NIMMO 1 (209 ) 744 - 0112 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 04- 1676 Ex . 3/31 / 19 8883064- UT 6/ 1 /2019 Spill Container Testing Training and Certifications (List applicable certifications.) Franklin Fueling - EBW & Phil Tite # 10009843708 Ex . 11 /29/2020 OPW # 104-632 Ex. 3/ 14/2020 RE ( III . SPILL CONTAINER TESTING INFORMATION Test Method Used : ❑x Manufacturer Guidelines (Specify): O P W ❑ Industry Code or Engineering Standard (Specify) : ENVIRONMENTAL HEALT ❑ Engineered Method (Specify): nFPARTMENT # of Attach the testing procedures and all documentation required to determine the results. Attached Pages TANK ID : (By tank number, stored product, etc.) 1 - 91 OCT 2 - 87 OCT 3 - DIESEL Spill Container Manufacturer: O P W O P W O P W Method of Cathodic Protection: ❑x Non-Metallic Z Non-Metallic 0 Non-Metallic ❑ Non-Metallic ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) Inside Diameter of Spill Container: (Inches) 11 11 11 Depth of Spill Container: (Inches) 14 13 3/4 12 1 /2 Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑x Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No I Method to Kee Spill Container Empty: x p p' ❑x Drain Valve Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : R Pass ❑ FaiIj Z Pass ❑ Fail ❑x Pass ❑ Fail El Pass ❑ Fail V. COMMENTS Any 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 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 herein is accurate . UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council