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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Test ❑ Repair Test (] 12 Month Test I . FACILITY INFORMATION CERS ID Date of Spill Container Test 10180717 14/ 11 / 19 Business Name (Same as Facility Name or DBA-Doing Business As) Fast & Easy Morada #60 ( Stockton ) Business Site Address City ZIP Code 10878 N Highway 99 Stockton 95212 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # Timothy Capehart ( 800 ) 339 - 9930 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 804904 8414476 3/3/2020 Spill Container Testing Training and Certifications (List applicable certifications.) Opw 0167682 8/ 19 /20 111 . SPILL CONTAINER TESTING INFORMATION Test Method Used : ❑ Manufacturer Guidelines (Specify) : ❑x Industry Code or Engineering Standard (Specify) : PEI 1200 ❑ Engineered Method (Specify) : # of Attach the testing procedures and all documentation required to determine the results. Attached Pages TANK ID : (By tank number, stored product, etc.) Premium - 1 Premium-2 Unleaded Diesel Spill Container Manufacturer: Opw Opw Opw Opw Method of Cathodic Protection : ❑x Non-Metallic Non-Metallic Z Non-Metallic Z Non-Metallic ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) Inside Diameter of Spill Container: (Inches) 11 . 0" 11 . 0" 11 . 0" 11 .01, Depth of Spill Container: (Inches) 11 . 0" 12. 5" 12. 5 12. 5 Does the spill container have a 5 gallon capacity? ❑ Yes Z No El Yes ❑ No Z Yes ❑ No (] Yes ❑ No Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve Z Drain Valve ❑x Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : Pass Z Fail Z Pass ❑ Fail 0 Pass ❑ Fail J 0 Pass ❑ Fail V. COMMENTS Any items marked "Fail' above must be explained in this section . Any additional comments may also be provided here . The premium 1 opw fill spill bucket does not hold 5 gallons . Due to being a direct buried opw spill bucket we will have to return and break concrete to make riser adjustments and replace the spill bucket and retest . Unleaded fill spill bucket failed hydrostatic test due to leaking fill cap retested with pass. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations , Title 23 , Division 3 , Chapter 16 , Section 2637 . 1 and all the information contained herein is accurate . UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = Cafifomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Coundl UNA08 www, unidocs. org 1 /1 - Rev. 06/14/18