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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 ❑x 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180893 4 / 16 /2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Quik Stop Market # 132 <br /> Business Site Address City ZIP Code <br /> 3555 W Hammer Lane Stockton 195219 <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 /> Anthony Reyes ( 916 ) 372 - 1885 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 617238 8293772 9/ 16/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW Tech# 103920 , PhikTite Tech# 1003213709 <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 /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> TANK ID : (By tank number, stored product, etc.) 87 Gasoline 91 Gasoline89 Gasoline <br /> jSpill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection : ZNon-Metallic Z Non-Metallic EZX Non-Metallic ❑ Non-Metallic <br /> El Isolation El Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) [E] <br /> Other (Specify in V.) <br /> Inside Diameter of spill Container: (Inches) 11 . 5 11 . 5 11 . 5 <br /> Depth of Spill Container: (Inches) 14 14 14 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No El Yes ❑ No 0 Yes ❑ No Yes ❑ No <br /> ethod to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ❑x Drain Valve Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : L Z 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 /> 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 , Title 23, Division 3 , <br /> Chapter 16, Section 2637 . 1 and all the information contained herein is accurate. <br /> UST Service Technician Signature n <br /> If the 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 />