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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 /> 1. FACILITY INFORMATION <br /> CERS ID D e of Spill Container Test <br /> 10182265 # /17/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) NOV <br /> I <br /> ARCO AM PM # 82602 <br /> Business Site Address City ZIP Code <br /> 2430 Joe Pombo Pkwy. E NIVIH 0NMEWLT(00Y% LTH 95376 <br /> II. UNDERGROUND STORAGE TA SVIlk ECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Celcation.) Phone # <br /> Guadalupe Sanchez (925) 470 - 0803 Ext. <br /> Contractorrrank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1005444 5250451 4/8/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW # 0163755 Expites : 6/18/2019 FFS EVR Phase l Systems # 1031393709 Expires: 3/4/2020 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑ Manufacturer Guidelines: (Specify) <br /> ® Industry Code or Engineering Standard: (Specify) PEURP1200- 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 M West T1 : 87 M East T2 : 87 Syphon T3 : 91 <br /> Spill Container Manufacturer. OPW OPW OPW OPW <br /> ❑ NonWetatlic ❑ 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) <br /> 11 11 " <br /> Depth of Spill Container: (inches) 17 161 /2 161 /8 17" <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 ❑ Faii <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 /> 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 /> If the facility has more components Wan this form commodates, additional copies of this page may be attached. <br /> r.FP.q = ra *vnia FnuhrwwL4%t a Ravnf inn .RuQtpm In = rttnntiflratinn 1 LCT = 1 inr&wyw and ctnmm rank irr = Intama kmW r 1P rn, mrq <br />