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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 Z 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10182107 6/ 11 /2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Quick Stop Market # 124 <br /> Business Site Address City ZIP Code <br /> 505 N . Main St Manteca 95336 <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 /> ( 916 ) 372 - 1885 <br /> Contractor I 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 /> Ill . 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 /> ❑ 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 <br /> E Depth of Spill Container: (Inches) 14 . 5 14 . 5 13 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No El Yes ❑ No El Yes ❑ No ❑ Yes ❑ No <br /> Method to Kee Spill Container Empty:Keep P� p Y [I Drain Valve El Drain Valve ❑ Drain Valve El Drain Valve <br /> x❑ Onsite Pump I] Onsite Pump ❑x Onsite Pump ❑ Onsite Pump <br /> I <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 : Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass El Fa <br /> 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 /> t' <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />