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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 />I. FACILITY INFORMATION <br />CERS ID Date of Spill Container Test <br />10180783 5/9/2019 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />STOCKTON PETROLEUM - JAMAR SERVICE <br />Business Site Address City ZIP Code <br />4075 E MAIN ST STOCKTON, CA 95201 <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 />FELIX RAMIREZ (209) 744-0112 <br />Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />08-1740 5-31-20 8883072 -UT 11/9/2020 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tite #1009883708 11/29/20 <br />OPW #104634 3-14-20 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: ❑x Manufacturer Guidelines (Specify): LAKE TEST <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br /># of Attached Pages <br />Attach the testing procedures and all documentation required to determine the results. <br />TANK ID: (By tank number, stored product, etc.) <br />Spill Container Manufacturer: <br />Method of Cathodic Protection: <br />Inside Diameter of Spill Container: (Inches) <br />Depth of Spill Container: (Inches) <br />Does the spill container have a 5 gallon capacity? <br />Method to Keep Spill Container Empty: <br />IV. <br />Spill Container Test Results: <br />87 <br />OPW <br />� Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V) <br />11 <br />iLAI <br />91 <br />OPW <br />❑x Non -Metallic <br />❑ Isolation <br />❑ Other (Specifyin V) <br />11 <br />l i. <br />� Yes ❑ No ❑x Yes ❑ No <br />❑x Drain Valve ❑x Drain Valve <br />❑ Onsite Pump [:]Onsite Pump <br />❑ Other (Specify in V.) El Other (Specify in V.) <br />SUMMARY OF TESTING RESULTS <br />❑x Pass ❑ Fail ❑Q Pass ❑ Fail <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V) <br />❑Yes ❑ No <br />❑ Drain Valve <br />El Onsite Pump <br />00 <br />ther (Specify in V.) <br />El Pass ❑Fail <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑ Yes ❑ No <br />❑ Drain Valve <br />ElOnsite Pump <br />ElOther (Specify in V.) <br />❑ Pass ❑Fail <br />V. COMMENTS <br />Any items marked "Fail" above must be explained in this section. Any additional comments y also be rovided here. <br />!!.SAY a 0 rOtg <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCT <br />I hereby certify that the spill containers were tested in accordance with California Code <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 maybe attached. <br />CERS = California Environmental Reporting System, ID = Identfication, UST =Underground Storage Tank, ICC = International Code Coundl <br />Tile 23, Division 3, <br />