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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 IDDate of Spill Container Test <br /> 10468777 10/24/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> ARCO AM/PM # 83333 <br /> Business Site Address City ZIP Code <br /> 550 W. Valpico Ave . Tracy 95376 <br /> II, UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certirication.) Phone # <br /> Guadalupe Sanchez (925) 470 - 0803 Ext. <br /> Contractorfrank 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 /> FFS EVR Phase I Systems # 1031393709 Expires : 3/4/2020 OPW # 0163755 Expires 6/18/2019 , <br /> III. SPILL CONTAINER TESTING INFORMATION° °¢ <br /> Test Method Used: <br /> ❑ Manufacturer Guidelines: (Specify) <br /> J C. .. _. <br /> ® Industry Code or Engineering Standard: (Specify) PEI/RP1200-17 <br /> ❑ Engineered Method: (Specify) 1=: NWR� NSMIi I` $ VA HE Al: I <br /> Attach the testing procedures and all documentation required to determine the results. of A a� Pages <br /> Tank ID: (By tank number, stored product, etc.) T1 : 87 West T1 : 87 East T2: 91 Ti Diesel <br /> Spill Container Manufacturer. Phil-Tite Phil-Tite Phil-Tite Phil-Tite <br /> ❑ Non-Metallic ❑ 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) 12" 12„ 12 to <br /> 12" <br /> Depth of Spill Container: (inches) 15" 151 /2 11 16" 161 /4" <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No ® Yes ❑ No 10 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 /> (Spec fy 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 ❑ Fall ® Pass ❑ Fail <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 /> I 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 than this form accommodates, a ditionet copies of this page may be attached. <br /> MRC a r.aJ* mia Fnvin nnwwt l RonnMnn Svctom m r.. Wan*floi iii I Wfi I Irrlomrrvmrd Qfniii tank Irx: a trema kvW r w1a rjumrn <br />