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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Test ❑ Repair Test 0 12 Month Test I . FACILITY INFORMATION CERS ID Date of Spill Container Test 10182251 2/7/2019 Business Name (Same as Facility Name or DBA-Doing Business As) ARCH ROAD AM / PM Business Site Address ___—TCity ZIP Code 4855 S . HIGHWAY 99 STOCKTON , CA 95205 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # ZANE NIMMO (20 9 ) 744- 0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 04- 1676 Ex . 3/31 / 19 8883064 - UT 6/ 1 /2019 Spill Container Testing Training and Certifications (List applicable certifications.) Franklin Fueling - El3W & Phil Tite # 10009843708 Ex . 11 /29/2020 OPW # 104-632 Ex . 3/ 14/2020 III . SPILL CONTAINER TESTING INFORMATION Test Method Used : ❑x Manufacturer Guidelines (Specify) : O P W PHASE I ❑ Industry Code or Engineering Standard (Specify) : , E N1 ❑ Engineered Method (Specify) : # of Attached Pages Attach the testing procedures and all documentation required to determine the results. TANK ID : (By tank number, stored product, etc.) 1 - 87 North 2 - 87 South 3 - 89 OCT 4 - 91 OCT Spill Container Manufacturer: O F W o P W O P W O P W Method of Cathodic Protection: Non- Metallic 0 Non-Metallic 0 Non-Metallic 0 Non-Metallic ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) Inside Diameter of Spill Container: (Inches) 11 11 11 11 Depth of Spill Container: (Inches) 12 1 /2 12 12 12 1 /2 Does the spill container have a 5 gallon capacity? R Yes ❑ No ❑x Yes ❑ No ❑x Yes ❑ No 0 Yes ❑ No Method to Keep Spill Container Empty: ❑x Drain Valve 0 Drain Valve Drain Valve Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Other (Specify in V) ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : (] Pass [01 ail 0 Pass El Fail 0 Pass ❑ Fail Pass El 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 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