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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 0 12 Month Test <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10190667 5/21 /2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Quick Stop # 121 <br /> Business Site Address City ZIP Code <br /> 1196 W . Louise Ave 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 /> Curtis Carpenter ( 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 /> 111 . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify) : <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify) : <br /> # of <br /> Attach the testing procedures and all documentation required to determine the results. Attached Pages <br /> TANK ID : (By tank number, stored product, etc.) 1 -87 2 -91 <br /> Spill Container Manufacturer: OPW OPW <br /> Method of Cathodic Protection : ❑x Non-Metallic ❑x Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (specify in V) ❑ Other (specify in V.) ❑ Other (Specifyin V.) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 13 13 <br /> Depth of Spill Container: (Inches) 13 13 <br /> Does the spill container have a 5 gallon capacity? 9 Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑x Onsite Pump 0 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 : 9 Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail ❑ 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. 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 />