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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 2112 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Tett <br /> 10181087 8 /26/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Arco 2093 <br /> Business Site Address City ZIP Code <br /> 3425 Tracy 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 /> David Rouse ( 925 ) 551 -7555 <br /> Contractor f Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 220793 8292530 6/28/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications ) <br /> Franklin Fueling Tech Cert # 1005763709 <br /> flim SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) <br /> ❑x Industry Code or Engineering Standard (Specify) 1 hour hydrostatic, Tape Measure <br /> ❑ Engineered Method (Specify) <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages <br /> TANK 10 : (By tank number, storedproduct, etc.) T1 -87 Fill T2-87 Fill T3- 87 Fill T4- 91 Fill <br /> Spill Container Manufacturer' PhikTile Phil•Tite Phil-Tile PhikTile <br /> Method of Cathodic Protection 0 Non-Metallic ❑x Non-Metallic 0 Non• Metaliic I] NonWetailic <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) 12 12 12 12 <br /> Depth of Spill Container (inches) 15 15 15 15 <br /> Does the spill container have a 5 gallon capacity'r 0 Yes ❑ No Q Yes ❑ No 0 Yes ❑ No 0 Yes ❑ No <br /> Method to Keep Spill Container Empty E) Drain Valve (] Drain Valve ❑x Drain Valve ® Drain Valve <br /> ❑ Onsite Pump ❑ Onsile Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Speedy in V ) ❑ Other (Specify in V ) I [] Other (Speedy in V ) ❑ Other (specify in v ) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results I@ Pass [] Fail 0 Pass ❑ Fad (] Pass ❑ Faii ® Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked 'Fart 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 info r atio ntained herein is accurate. <br /> UST Service Technician Signatur <br /> if the facility has more compidifents than this form accommodates, additional copies of this page may be attached, <br /> CERS = CaMomia Environmental Reporting System ID = Identification UST = Underground Storage Tank, ICC - International Code Council <br /> I <br />