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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 /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10402351 10/22/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> ARCO AM/PM # 83230 <br /> Business Site Address City ZIP Code <br /> 1340 W. Colony Rd. Ripon 95366 <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 /> Guadalupe Sanchez (925)470 - 0803 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1005444 5250451 04/05/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> FFS EVR Phase I Systems# 1031393709 Expires: 03/04/2020 OPW#0163755 Expires: 06/07/2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑Manufacturer Guidelines:(Specify) <br /> ®Industry Code or Engineering Standard:(Specify) PEI/RP1200-17 <br /> ❑Engineered Method:(Specify) <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> Tank ID:(By tank number,stored product,etc.) T1: 87 West T1: 87 East T2: 91 T3: Diesel <br /> Spill Container Manufacturer. Phil-Tate Phil-Tite Phil-Tite Phil-Tite <br /> ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> Method of Cathodic Protection ®Isolation ®Isolation ®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) 11 1/4" 11 1/4" 11 1/4" 11 1/4" <br /> Depth of Spill Container.(inches) 16" 15" 16" 16 1/4" <br /> Does the spill container have a 5 gallon capacity? ®Yes ❑No ®Yes ❑No ®Yes ❑No ®Yes ❑No <br /> ®Drain Valve ®Drain Valve ®Drain Valve ®Drain Valve <br /> Method to Keep Spill Container Empty ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Specify in section V.) (Specify in section V.) (Specify 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 /> All items marked Fail"above must be explained in this section.Any additional comments may also be here.` P3 <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING Tal 11110 <br /> I hereby certify that the spill containers were tested in accordance with Callfomia Code of Regulations,title&j divisia6 3;chapter 16,section <br /> 2637.1 and all the information contained herein Is accurate. <br /> UST Service Technician Signature <br /> !f the facility has more components than this form accommoddles,additional oples of this page may be attached. <br /> r`FM=ratifnmLq Fmitnvvnar#W Rarvwfl n.quo li xn in=k1uMifu-,it1 , 1 RT=1 Irviarrvry ind ctnrana bnk Irr=IntamatkvwJ r"fp rim mru <br />