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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM(Page 1 of 1) Type of Action ❑Installation Test ❑Repair Test 2112 Month Test I. FACILITY INFORMATION CERS ID Dale of Spill Container Test 1/22/2019 Business Name(Same as Facility Name or DBA-Doing Business As) Arco 6080 Business Site Address City ZIP Code 85 E Louise Ave Lathrop 95330 IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the/CC Certification) Phone# David Rouse (925) 551-7555 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 220793 8292530 6/28/2020 Spill Container Testing Training and Certifications(List applicable cerfirications) III. SPILL CONTAINER TESTING INFORMATION Test Method Used ❑Manufacturer Guidelines(Specify) ❑x Industry Code or Engineering Standard(Specify) HydrostaiC, Tape Measure ❑Engineered Method(Specify) Attach the testing procedures and all documentation required to determine the results. #of Attached Pages TANK ID:(By lank number,stored product,etc.) T1 Unleaded (A) T1 Unleaded(B) T2 Premium Spill Container Manufacturer OPW-Vapor OPW-Vapor DPW-Vapor Method of Cathodic Protection ❑Q Non-Metallic ❑x Non-Metallic ❑Q Non-Metallic ❑Non-Metallic ❑Isolation ❑Isolation ❑Isolation ❑Isolation ❑Other(Specity in,V) ❑Other(Specify in V) ❑Other(Specify in V) ❑Other(Specify in V) Inside Diameter of Spill Container(Inches) 12" 12" 12" Depth of Spill Container(inches) 14" 14" 14" Does the spill container have a 5 gallon capacity? Q Yes ❑No 1]Yes ❑No HI Yes ❑No ❑Yes ❑No Method to Keep Spill Container Empty ❑Drain Valve ❑Drain Valve ❑Drain Valve ❑Drain Valve x❑Onsite Pump ❑x Onsite Pump ❑x 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 ❑x Pass ❑Fail I ❑x Pass []Fad x❑Pass ❑Fail ❑Pass ❑Fa I 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 contai herein Is accurate. UST Service Technician Signature If the facility has more components thfiffthis form accommodates,additional copies of this page maybe attached. CERS=California Environmental Reporting System ID=Identification.UST=Underground Storage Tank.ICC=International Code Cound