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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 /> 12/ 13/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Arco 7049 <br /> Business Site Address City ZIP Code <br /> 800 E . Kettleman Lane Lodi 95240 <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 /> David Rouse ( 925 ) 5514777 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 220793 8292530 6128/2020 <br /> Spill Container Testing Training and Certifications (fist applicable certifications.) <br /> N/A <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑ Manufacturer Guidelines (Specify): <br /> 0 Industry Code or Engineering Standard (Specify): Hydrostatic / Tape Measure <br /> ❑ Engineered Method (Specify): <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages 12 <br /> TANK ID: (By tank number, storedproduct, etc.) T1 - Unleaded T2-Unleaded T3- Unleaded T4-Premlum <br /> Spill Container Manufacturer: EBW- Product EBW- Product EBW- Product EBW- Product <br /> Method of Cathodic Protection (,x NonWetallic 0 Non-Metallic ❑x Nan-Metallic 0 Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ isolation ❑ isolation <br /> ❑ Other (Specify in V ) ❑ Other (Specify in V) ❑ Other (Specify in V ) ❑ Other (Specify in V ) <br /> Inside Diameter of Spill Container: (Inches) 13° 13" 13" 13" <br /> Depth of Spill Container: (inches) 101 /2 101 /2 101 /2 101 /2 17 <br /> Does the spill container have a 5 gallon capacity? El Yes ❑ No 0 Yes ❑ No 0 Yes D No Q Yes ❑ No <br /> Method to Keep Spilt Container Empty, ❑x Drain Varve Drain Valve N Drain Valve 0 Drain Valve <br /> E3 Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> [] Other (specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ; O Pass ❑ Fail 0 Pass El Fail 0 Pass El Fail 0 Pass El 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 /> 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 c ntai herein Is accurate. <br /> UST Service Technician Signalure <br /> If the facility has more components th this form accommodates, additional copies of this page may be attached. <br /> i <br />€ CERS = Cafdomia Environmental Reporting System, ID = klenti icalion. UST = Underground Storage Tank, ICC = international Code Count <br /> I <br /> I <br />