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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Test ❑ Repair Test ❑x 12 Month Test I . FACILITY INFORMATION CERS ID Date of Spill Container Test 10182153 12/ 11 /2018 Business Name (Same as Facility Name or DBA-Doing Business As) LATHROP GAS & FOOD Business Site Address City ZIP Code 140 E . LATHROP ROAD LATHROP , CA 95330 ll . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # ZANE NIMMO (209 ) 744 - 0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 04- 1676 Ex . 3/31 / 1 8883064 - UT 6/ 1 /2019 Spill Container Testing Training and Certifications (List applicable certifications.) Franklin Fueling - EBW & Phil Tite # 10009843708 Ex . 11 /29/2020 OPW # 104-632 Ex . 3/ 14/2020 III . SPILL CONTAINER TESTING INFORMATION 4 Test Method Used : ❑x Manufacturer Guidelines (Specify) : O P W PHASE 1 ' nn1 ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, storedproduct, etc.) 1 - 87 OCT 2 - 91 OCT 3 - DIESEL 2 Spill Container Manufacturer: O P W O P W O P W Method of Cathodic Protection : Q Non-Metallic 0 Non-Metallic 0 Non-Metallic ❑ Non-Metallic ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation ❑ Other (Specify in V) ❑ Other (Specify in v) ❑ Other (Specify in V.) ❑ Other (SpecidNo Inside Diameter of Spill Container: (Inches) 11 11 11 Depth of Spill Container: (Inches) 14 13 1 /2 14 1 /2 Does the spill container have a 5 gallon capacity? El Yes ❑ No ❑x Yes ❑ No 0 Yes ❑ No ❑ Yes Method to Keep Spill Container Empty: 9 Drain Valve 0 Drain Valve ❑x Drain Valve ❑ Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specify in v.) ❑ Other (Specify in V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : IK Pass ❑ Fail 0 Pass ❑ Fail Q Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations , Title 23 , Division 3 , Chapter 16 , Section 2637 . 1 and all the information contained herein is accurate . UST Service Technician Signature OAAE if the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council