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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 />10180943 2/5/2019 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />SHOP N GO <br />Business Site Address City ZIP Code <br />4511 PACIFIC AVE STOCKTON, CA 95207 <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 />DAVID WINKLER (209) 744-0112 <br />Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />08-1739 Ex.3/31 /20 8883059-UT 1/29/2020 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tite #10009853708 Ex. 11/29/20 <br />OPW #104-633 Ex. 3/14/2020 <br />i, <br />III. SPILL CONTAINER TESTING INFORMAtfbN <br />Test Method Used: ❑x Manufacturer Guidelines (Specify): WATER TEST <br />MAR _ <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): ENVIt NMENTAL IEALTH <br />r ]T <br />IK <br />Attach the testing procedures and all documentation required to determine the results. #hdges <br />TANK ID: (By tank number, stored product, etc.) 87 91 <br />Spill Container Manufacturer: OPW OPW <br />Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br />❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br />❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) <br />Inside Diameter of Spill Container: (Inches) 11 11 <br />Depth of Spill Container: (Inches) 14 14 <br />Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No R Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br />Method to Keep Spill Container Empty: ❑x Drain Valve X Drain Valve ❑ Drain Valve ❑ Drain Valve <br />❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br />❑ Other (Specifyin V.) I ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: ❑Q Pass ❑Fail x❑ Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail <br />V. COMMENTS <br />Any 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 California Code of Regulations, Title 23, Division 3, <br />Chapter 16, Section 2637.1 and all the information contained herein is accurate. <br />UST Service Technician Signature W <br />If the facility has more components than this form accommodates, additional copies of this page maybe <br />CERS = California Environmental Reporting System, ID = Identfication, UST =Underground Storage Tank, ICC = International Code Coundl <br />