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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM <br /> Type of Action ❑ Installation Test ❑ Repair Test ® 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID : Date : <br /> 4/26/2019 <br /> Business Name <br /> Arco AmPm- Trinity Parkway <br /> Business Site Address City Zip Code <br /> 10715 Trinity Parkway Stockton <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Business Name & Address : BZ Service Station Maintenance — 1041 Triangle Ct, West Sacramento CA <br /> Name of UST Service Technician Performing the Test Darnell Smith Phone # 916-371- 2380 <br /> Contractor License # 433159 ICC Certification tl 8709494 ICC Expiration Date 12/21/2019 <br /> Spill Container Testing Training and Certification (List applicable certification . ) <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer (Specify): <br /> ® Industry Code or Engineering Standard (Specify) : PEI 1200 Pg . 11 <br /> Hydrostatic ❑ Engineered Method (Specify) : <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages : <br /> TANK ID : (By tank #, stored product, etc) 87 91 DSL 87 <br /> Spill Container Manufacturer : OPW OPW OPW OPW <br /> Method of Cathodic Protection : ❑ Non- Metallic ❑ Non - Metallic ❑ Non - Metallic ❑ Non - Metallic <br /> ® Isolation ® Isolation ® Isolation ® Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> Inside Diameter of Spill Container : (Inches) 111/211 111/2 " 111/2" 111/2" <br /> Depth of Spill Container : (Inches) 125/8 If 127/811 121/411 12 3/8" <br /> Does the spill container have a 5 gallon ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No <br /> capacity? <br /> Method to Keep Spill Container Empty : ® Drain Value ® Drain Value ® Drain Value ® Drain Value <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ® Pass ❑ Fail I ® 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 hearby certify that the spill containers were tested in accordance with California Code of Regulations, Title 23, Division 3, Chapter 16, Section <br /> 2637 . 1 and all the information contained herein is accurate . <br /> UST Service Technician Signature <br />