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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test Q Repair Test 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181087 8/2612019 <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 I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 220793 8292530 6/28/2020 <br /> Spill Container Testing Training and Certifications (List applicable certirications.) <br /> Franklin Fueling Tech Cert # 1005763709 <br /> 1110 SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used ❑ Manufacturer Guidelines (Specify) <br /> E] Industry Code or Engineering Standard (Specify) <br /> 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 ID: (By tank number, stored product, etc ) T1 -87 Vapor T2 -$7 Vapor TM7 Vapor T4 -91 Vapor <br /> Spill Container Manufacturer: PhilTite Phil-Tite PhilTite Phil Tite <br /> Method of Cathodic Protection I] NonWetallic Q Non4etallic E] Non •Melallic 2) Non-Metall c <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? I] Yes ❑ No M Yes ❑ No Yes ❑ No CE Yes ❑ No <br /> Method to Keep Spill Container Empty: Q Drain Valve Q Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> I] Onsite Pump N Onsite Pump E] Onsite Pump ® Onsite Pump <br /> ❑ Other (Specify in V ) Q Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results. Pass Q Fail E] Pass ❑ Fail E] Pass ❑ Fail E] Pass ❑ 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 .9 and all the infor <br /> patio ntained herein is accurate . <br /> UST Service Technician Signatur <br /> If the facility has more comptfrTents 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 /> t <br /> i <br />