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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 ® 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181433 12/19/ 18 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> March Ln 76 <br /> Business Site Address City ZIP Code <br /> 2701 West March Ln Stockton 95219 <br /> 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Kristopher Bell (408 ) 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 78833000 7/22/20 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 1044933708 <br /> 111 . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ® Manufacturer Guidelines (Specify): OPW 2100 Series <br /> ® Industry Code or Engineering Standard (Specify): PEI RP 1200 <br /> ❑ Engineered Method (Specify): <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. 1 <br /> TANK ID : (By tank number, stored product, etc.) 1 Regular 2 Prem 3 Diesel 4 <br /> Spill Container Manufacturer: Phii-Tite PhiiJite PhikTite <br /> Method of Cathodic Protection : ® Non-Metallic ® Non-Metallic ® Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in v.) ❑ Other (specify in V.) ❑ Other (Specifyin V.) <br /> Inside Diameter of Spill Container: (Inches) 13" 13 " 13" <br /> Depth of Spill Container: (Inches) 13 " 12. 50" 13 . 50" <br /> Does the spill container have a 5 gallon capacity? ❑ Yes © No ❑ Yes ® No © Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ® Drain Valve ® Drain Valve ® 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 (Specifyin V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : L Pass ❑ Fail ® 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 /> Replaced 91 drain and o-ring due to failing . Retested & Passed . <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 <br /> i <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Caffomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council <br />