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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 rxl 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 6/ 18/2019 <br /> Business Name (same as Facility Name or DBA*Doing Business As) <br /> Arca 7147 <br /> Business Site Address City ZIP Code <br /> 1206 E . March Lane Stockton 95210 <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 /> David Rouse ( 925 ) 551 -7555 <br /> Contractor Tank Tesler License # ICC Certification # ICC Certification Expiration Dale <br /> 220793 8292530 6/28/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications ) <br /> OPW Tech Cert # 108211 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used Q Manufacturer Gwdelines (Specify) <br /> ® Industry Code or Engineering Standard (Specify) <br /> Hydrostatic , Tape Measure <br /> ❑ Engineered Method (Specify). <br /> # <br /> Attach the testing procedures and all documentation required to determine the results. of Attached Pages <br /> TANK ID : (By tank number, stored product. etc ) T1 Unleaded T2 Premium T3 Diesel <br /> Spill Container Manufacturer OPW Vapor OPW Vapor OPW Vapor <br /> Method of Cathodic Protection 9 Non•Metallic Non•Metalfic Qx Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (specify et v ) Q Other (specify in v ) 0 Other (Specify rn V ) ❑ Other (Specify on V ) <br /> Inside Diameter of Spill Container (inches) 12 1 2 12 <br /> Depth of Spill Container (Inches) 14 14 14 <br /> Does the spill container have a S gallon capacity" n Yes Q No M Yes Q No ® Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty Q Drain Valve Q Drain Valve Q Drain Valve ❑ Drain Valve <br /> 0 Onsite Pump Onsite Pump ® Onsite Pump ❑ Onsite Pump <br /> Q Other (Specify in V ) ❑ Other (Specdy in v ) ❑ Other (specify in V ) Q Other (Specify rn V ) <br /> IV, SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results (] Pass [IFaii ❑x Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fal <br /> V. COMMENTS <br /> Any items marked "Fad ' 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 spilt containers were tested in accordance with California Code of Regulations , Title 23, Division 3, <br /> Chapter 16 , Section 2637.1 and all the inforrinaflw conlp <br /> Yned herein is accurate. <br /> UST Service Technician Signature <br /> if the facility has more componenhan this form accommodates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, 10 = Identification. UST m Underground Storage Tank, ICC International Code Councif <br />