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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Test ❑ Repair Test UD 12 Month Test L FACILITY INFORMATION CERS ID Date of Spill Container Test 6/ 18/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Arco 7147 Business Site Address City ZIP Code 1206 E . March lane Stockton 95210 lie UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification ) Phone # David Rouse 1 ( 925 ) 551 -7555 Contractor 1 Tank Tester License # ICC Certification # ICC Certification Expiration Dale 220793 8292530 6/28/2020 Spill Container Testing Training and Certifications (List applicable certifications ) OPW Tech Cert # 108211 III . SPILL CONTAINER TESTING INFORMATION Test Method Used ❑ Manufacturer Guidelines (Specify) 21 Industry Code or Engineering Standard (Specify) Hydrostatic , Tape Measure ❑ Engineered Method (Specify) Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK ID: (By lank number stored product. etc ) Ti Unleaded T2 Premium T3 Diesel Spill Container Manufacturer OPW Fill OPW Fill DPW Fill Method of Cathodic Protection Non•Metallic [E Non•Metallic (—}x, Non-Metallic ❑ Non •Metaliic ❑ Isolation ❑ isolation Ei Isolation ❑ Isolation ❑ Other (Specify in V ) ❑ Other (specify in v ) ❑ Other (Specify in V ) ❑ Other (Specify in 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 ❑x Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No Method to Keep Spill Container Empty Drain Valve 0 Drain Valve 21 Drain Valve ❑ Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump Cl Onsite Pump I] Other (Specify in V ) ❑ Other (Specify in V ) [] Other (Specify in V ) ❑ Other (Specify in V ) 91 IV. SUMMARY OF TESTING RESULTS Spill Container test Results 21 Pass ❑ Fa U Pass ❑ Fail E Pass ❑ Fail ❑ 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 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 lnformatiqn con ed herein is accurate. UST Service Technician Signature If the facility has more componenti1han this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = identification . UST 7 Underground Storage Tank, ICC = Intemational Code Council