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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 ® 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID T'Date Spill Container Test <br /> 10761034 4/8/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> ARCO AM/PM # 83831 <br /> Business Site Address City ZIP Code <br /> 1904 Daniels St. Manteca 95337 <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 /> Guadalupe Sanchez (925) 470 - 0803 Ext. <br /> Contractorfrank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1005444 5250451 4/5/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> FFS EVR Phase I Systems # 1031393709 Expires : 3/4/2020 OPW # 0163755 Expires : 6/18/2019 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑ Manufacturer Guidelines: (Specify) <br /> ® Industry Code or Engineering Standard: (Specify) PEI/RP1200A 7 <br /> ❑ Engineered Method: (Specify) <br /> Attach the testing procedures and all documentation required to determine the results. # of Alta 2r <br /> Pages <br /> Tank ID: (By tank number, stored product etc.) 87 North T1 : 87 South T2: 91 T33: Diesel <br /> Spill Container Manufacturer: W OPW OPW OPW <br /> [OF] on-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection olation ® isolation 19 Isolation ® Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container: (Inches) <br /> 11 11 " <br /> Depth of Spill Container. (inches) 161 /2 17 155/8 17" <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No 10 Yes ❑ No <br /> ® Drain Valve ® Drain Valve 10 Drain Valve ® Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onske Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Speclly in section V.) (Speclly in section V.) (Specify in section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail <br /> V. COMMENTS <br /> Ali items marked 'Fail" above must be explained in this section. Any additional comments may also be provided here. <br /> i <br /> i <br /> i <br /> i <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, chapter 16, section <br /> 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, addit nal copies of this page may be attached. <br /> (:FRC a rW ifnmin Fm4mro"mW RPmffinnCuctom in a kIm*ffralinn I LST a I Indommm Ind ctmmnp tank I(:(: m intwemflnnal rrvia f:n+ tncn <br />