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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 ❑X 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181565 1 / 15/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> PERSHING GAS <br /> Business Site Address City ZIP Code <br /> 4445 PERSHING AVE ISTOCKTON , CA 95207 <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 I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 0 & 1740 5-31 -20 8883072 - UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tile # 1009883708 11 /29/20 <br /> OPW # 104634 3- 14-20 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑X Manufacturer Guidelines (Specify) : OPW 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 : (Bytanknumber, storedproduct, etc.) 87 91 DIESEL <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑X Non-Metallic ❑X Non-Metallic Z Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) <br /> Inside Diameter of Spill Container: (Inches) 11 11 11 <br /> Depth of Spill Container: (Inches) 14 14 14 <br /> Does the spill container have a 5 gallon capacity? D Yes ❑ No El Yes ❑ No Z Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: (] Drain Valve X❑ Drain Valve Z Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ 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 : F Z Pass ❑ Fail Z Pass ❑ Fail ❑X 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 prgei6 '} <br /> rEB 04 2019 <br /> ENVIRONMENTAL <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 A ' V <br /> If the facilityhas more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = Calgomia Environmental Reporting System, ID = Identfication, UST = Underground Storage Tank, [CC = International Code Coundl <br />