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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM(Pagel of 1) <br /> Type of Action ❑Installation Test ❑Repair Test E 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10182265 10/17/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> ARCO AM PM#82602 <br /> Business Site Address City ZIP Code <br /> 2430 Joe Pombo Pkwy. Tracy 95376 <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 /> OPW#0163755 Expites: 06/07/2021 FFS EVR Phase I Systems# 1031393709 Expires: 03/04/2020 <br /> 111. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑Manufacturer Guidelines: (Specify) <br /> E 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 Pages3 <br /> Tank ID:(By tank number,stored product,etc.) T1: 87 M West T1: 87 M East T2: 87 Syphon T3: 91 <br /> Spill Container Manufacturer. OPW OPW OPW OPW <br /> ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> Method of Cathodic Protection E Isolation ®Isolation E Isolation E 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" 11" 11" <br /> Depth of Spill Container.(Inches) 16 1/2" 17" 16 3/8" 16 3/4" <br /> Does the spill container have a 5 gallon capacity? E Yes ❑No E Yes ❑No E Yes ❑ No E Yes ❑No <br /> E Drain Valve E Drain Valve E Drain Valve E 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 E Pass ❑Fall E Pass ❑Fail E Pass ❑Fail E Pass ❑Fail <br /> V. COMMENTS <br /> All items marked'Fail"above must be explained in this section.Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the spill containers were tested in accordance with Callfor ila 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 accom odates,add donal copies of this page may be attached. <br /> rxRC c('sd;tr,r.,la Fmmrrurux�fal Ra+nnrttm Cvcfr+m In a 44+ntiFiralinn I LCT a I trulorrnrn mrl afrrxw fanlr I(Y:=Irdnrt�aNnnal('.ruin fru urB <br />