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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FOP <br /> pAa of 1 ) <br /> Type of Action El Installation Test `' ❑ Repair l esf n 12 Month Test <br /> L FACE fTY 'INFORNIATION <br /> CERS ID 3 f9 P' , tQ Date of Spill Container Test <br /> 10181059 7t: i ` 8/6/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) � � � d ENTAL <br /> Quick Stop <br /> # 138ENV <br /> Business Site Address ;4= i ity ZIP Code <br /> 1153 Lincoln Blvd Tracy 95376 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> ( 916 ) 372 - 1885 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 617238 8167865 5/ 13/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW , PhikTite <br /> ilia 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. # of Attached Pages <br /> TANK ID : (By tank number, stored product, etc.) 1 -87 2 -89 3-91 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection : ❑x Non-Metallic N Non-Metallic Z Non-Metallic ❑ Non-Metallic <br /> I <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> i ❑ Other (specify in V.) ❑ Other (Specifyin V) ❑ Other (Specify in V.) ❑ Other (Specify in V) <br /> Inside Diameter of Spill Container: (Inches) 13 13 13 <br /> Depth of Spill Container: (Inches) 16 16_. 5 16 <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No ❑x Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑x Onsite Pump ❑x Onsite Pump ❑X 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 : ❑Q Pass ❑ Fail Pass [:1 Fail Pass ❑ Fail El 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 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 />