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UNDERGROUNDSTORAGETANK ' <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test Repair Test r 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10165777 9/9/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As . ) <br /> 7-ELEVEN 14113 , MKT 2368 <br /> Business Site Address City: Zip: <br /> 3040 BENJAMIN HOLT DR @ GRIGSBY STOCKTON 95219 <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 /> Jesus Saldivar (800 ) 8004633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8361393 6/ 13/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> ICC - CA UST Service Technician 8361393 06/13/2021 Tanknology Certification - Level III Spill Container Testing Certification Exam 115240 <br /> 06/09/2022 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : Manufacturer Guidelines : (Specify) <br /> r' Industry Code or Engineering Standard : (Specify) PEI RP 1200 <br /> F 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.) Fill T1 Fill T2 <br /> REGULAR SUPREME <br /> Spill Container Manufacturer: OPW OPW <br /> 170 Non-Metallic W Non-Metallic Non-Metallic Non-Metallic <br /> Method of Cathodic Protection r Isolation r Isolation Isolation Isolation <br /> r Other r Other F Other r 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) 12 12 <br /> Depth of Spill Container: ( Inches) 13 13 <br /> Does the spill container have a 5 gallon capacity ? wYes r No W Yes r No Yes r No r Yes r No <br /> W Drain Valve W Drain Valve Drain Valve Drain Valve <br /> Method to Keep Spill Container Empty r Onsite Pump r Onsite Pump r Onsite Pump Onsite Pump <br /> r Other r Other r 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 FI/, Pa;; Fail Pass F Fail FPass F Fail FPaSS F Fail <br /> V. COMMENTS <br /> All items marked failed above must be explained in this section . Any additional comments may also be provided here . <br /> REPLACED FILL CAP ON REG . FILL SUMP DUE TO BAD GASKET. . <br /> #634-TT4"-EVR . <br /> M. CERTIFICATION 13Y UST SERVICE TECHNICIAN CONDUCTING THIS <br /> 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 /> 6W <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached . <br /> CERS=California Environmental Reporting System, ID=Identification , UST= Underground storage tank, ICC=International Code Council <br />