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RECEIVED VIA EMAIL ON 04-11-2022 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Test ❑Repair Test 2 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180759 04/18/19 <br /> Business Name(Same as Facility!Name or DBA-Doing Business As) <br /> Mobil#68222 <br /> Business Site Address City ZIP Code <br /> 2132 Mariposa Rd. Stockton 95205 <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 /> Brian McPheely (408)971-2445 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8822062 11/9/19 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> 10143037081104773 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ®Manufacturer Guidelines(Specify): OPW <br /> ❑ Industry Code or Engineering Standard(Specify): <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.) 1 Regular 2 Plus 3 Prem 14 Diesel <br /> Spill Container Manufacturer: OPW OPW OPW OPW <br /> Method of Cathodic Protection: ®Non-Metallic ®Non-Metallic 2 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) 12 12 12 12 <br /> Depth of Spill Container:(Inches) 17 17 17 17 <br /> Does the spill container have a 5 gallon capacity? 2 Yes ❑No 2 Yes ❑No 2 Yes ❑No 2 Yes ❑No <br /> Method to Keep Spill Container Empty: ®Drain Valve ®Drain Valve 2 Drain Valve ®Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(specify in V.) ❑Other(Specify in V.) ❑Other(specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: 2 Pass ❑Fail 1 2 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 Techhnni_ciaanSiSiiggnature <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br />