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Type of Action <br />CERS ID <br />10181013 <br />UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />❑ Installation Test <br />I. <br />Business Name (Same as Facility Name or <br />Quick Stop Market #120 <br />Business Site Address <br />9321 Thornton Road <br />UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />h on the ICC Certification.) Phone # <br />❑ Repair Test <br />FACILITY INFORMATION <br />Business As) <br />Date of <br />City <br />Stockton <br />❑x 12 Month Test <br />Container Test <br />5/2/2019 <br />11. <br />ZIP Code <br />95209 <br />Name of UST Service Technician Performing the Test (Punt ass own (g 16) 372-1885 <br />Curtis Carpenter <br />ICC Certification # ICC Certification Expiration Date <br />Contractor /Tankf6l <br />r License # 8167865 5/13/2020 <br />7238 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />OPW, Phil-Tite <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: ❑x Manufacturer Guidelines (Specify): <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the testing procedures and all documentation required to determine the results. <br />TANK ID: (By tank number, stored product, etc.) <br />Spill Container Manufacturer: <br />Method of Cathodic Protection: <br />Inside Diameter of Spill Container: (/nches) <br />Depth of Spill Container: (Inches) <br />Does the spill container have a 5 gallon capacity? <br />Method to Keep Spill Container Empty: <br />Spill Container Test Results: <br />Any items <br />IV. <br />1-87 <br />OPW <br />x❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specifyin V) <br />11.5 <br />14 <br />2-91 <br />OPW <br />(] Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />11.5 <br />14 <br />of <br />❑ Non -Metallic <br />❑ Isolation <br />❑Other (Specifyin V) <br />❑x Yes ❑ No ❑x Yes LJ No <br />❑ Drain Valve ❑Drain Valve <br />❑x Onsite Pump Z Onsite Pump <br />❑ Other (Specifyin V.) ❑ Other (Specify in V.) <br />SUMMARY OF TESTING RESULTS <br />❑x Pass ❑ Fail 0 Pass ❑ Fail <br />"Fail" above must be explained in <br />V. COMMENTS <br />section. Any additional <br />❑Yes ❑ No <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specifyin V.) <br />❑ Pass ❑Fail <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specifyin V) <br />❑ Yes ❑ No <br />❑ Drain Valve <br />❑ <br />site Pump <br />❑ Other (Specify in V.) <br />❑ Pass ❑Fail <br />comments may also be provided here. <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCT�1 <br />I hereby certify that the spill containers were tested in accordance with California Code <br />Chapter 16, Section 2637.1 and all the information contained herein is accurate. <br />UST Service Technician Signature 00, <br />If the facility has more components <br />accommodates, additional copies of this page maybe <br />CERS = Cal'�fomia Environmental Reporting System, ID = Identfication, UST =Underground Storage Tank, ICC = International Code <br />Coundl <br />23, Division 3, <br />