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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test Repair Test 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10165857 1 9/4/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As . ) <br /> 7-ELEVEN #19976 , MKT 2368 <br /> Business Site Address City: Zip: <br /> 1399 N . MAIN ST. @ NORTHGATE MANTECA 95336 <br /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test ( Print as shown on the ICC Certification . ) Phone # <br /> Jarrod Cooke (800) 8004633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 5311523-UT 4/3/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW - EVR Phase 1 101019 01 /07/2020 ICC - CA UST Service Technician 5311523-UT 04/03/2021 <br /> 111. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : Manufacturer Guidelines: (Specify) opw <br /> Industry Code or Engineering Standard : (Specify) PEI RP 1200 <br /> Engineered Method : (Specify) <br /> Attach the testing procedures and all documentation required to determine the results . # of Attached Pages <br /> 1 <br /> Tank ID : (By tank number, stored product, etc.) Fill T4 : UNLEADED Fill T5 : PREMIUM <br /> RUL PUL <br /> Spill Container Manufacturer: OPW OPW <br /> W/ Non-Metallic r Non-Metallic Non-Metallic Non-Metallic <br /> Method of Cathodic Protection r Isolation r Isolation r Isolation r Isolation <br /> Other Other r Other r Other <br /> qenV) (Specify in section V) (Specify in section V) Specify in section V) <br /> Inside Diameter of Spill Container: ( Inches) 14 <br /> Depth of Spill Container: ( Inches) 13 <br /> j Does the spill container have a 5 gallon No Yes No ryes No ryes No <br /> capacity? ry <br /> e r Drain Valve r Drain Valve r Drain Valve <br /> mp F Onsite Pump F Onsite Pump r Onsite Pump <br /> Method to Keep Spill Container Emptyr Other r Other r Other <br /> S eciinsectonS ecif in section (Specify in section (Specify in section V <br /> ( P fY ( P Y Y ( P Y ) <br /> N. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Resultsi"riPass Fail rPass Fail F.PaSS r Fail FPass r Fail <br /> V. COMMENTS ` <br /> All items marked failed above must be explained in this section . Any additional comments may also be provided here . <br /> VI. CERTIFICATION BY USTSERVICE TECHNICIAN CONDUCTING THIS <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 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 components than this form accommodates , additional copies of this page may be attached . <br />[' CERS=California Environmental Reporting System, ID=Identification , UST=Underground storage tank, ICC=International Code Council <br /> i <br />