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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action r Installation Test Repair Test F' 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10165815 9/20/2019 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> 7- ELEVEN # 17334 MKT 2368 ( W747) <br /> Business Site Address City: Zip : <br /> 4501 N . PERSHING AVE. @ ROSEMARIE LN , STOCKTON 95207 <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 /> Clint Fuhrman (800) 800-4633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 9160945 5/2/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW - EVR Phase 1 904272 05/23/2021 <br /> Ill. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : Manufacturer Guidelines : (Specify) <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: (Sy tank number, stored product, etc.) Fill T-1 Fill T-2 <br /> RUL PUL <br /> Spill Container Manufacturer: OPW OPW <br /> F Non-Metallic r Non-Metallic Non-Metallic Non-Metallic <br /> Method of Cathodic Protection r Isolation r Isolation r Isolation r Isolation <br /> r Other r Other r Other r Other <br /> (Specify in section V) (Specify in section V) (Specify in section V) (Specify in section V) <br /> Inside Diameter of Spill Container: ( Inches) 12 12 <br /> Depth of Spill Container: ( Inches) 16 . 5 13 . 5 <br /> Does the spill container have a 5 gallon capacity? r Yes r No W Yes r No r Yes r No r Yes r No <br /> r Drain Valve F Drain Valve r Drain Valve r Drain Valve <br /> Method to Keep Spill Container Empty r Onsite Pump r Onsite Pump r Onsite Pump r Onsite Pump <br /> r Other r Other r Other r Other <br /> (Specify in section V) (Specify in section V) (Specify in section V) (Specify in section V) <br /> N. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results f7Pass r Fail ro Pass F Fail FPass 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 /> M. CERTIFICATION BY UST SERVICE 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 /> � 5zllll. <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 />