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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page I of 1 ) <br /> Type of Action El Installation Test El Repair Test N 12 Month Test <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10166191 05/26/20 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Hammer k5 Arco <br /> Business Site Address City ZIP Code <br /> 3201 W . Hammer Lane Stockton 95209 <br /> 11 , UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the /CC Certification .) Phone # <br /> Isaac Anderson 1 (209 ) 532 7320 Ext. <br /> Contractor/Tank Tester License # ] CC Certification # ICC Certification Expiration Date <br /> CA 623541 /09� 1 749 8146912 06/ 12/20 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> CIPW # 100456 exp 05/ 11 /22 <br /> Ill . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : <br /> 9 Manufacturer Guidelines : (Specify) 1 Hour Hydrostatic Test <br /> [:1 Industry Code or Engineering Standard : (Specify) <br /> El Engineered Method : (Specify) <br /> # of ttached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> Tank ID : (By tank number, stored product, etc.) 87A Syphon Fill 87B Master Fill 91 Fill <br /> Spill Container Manufacturer: CIPW CIPW CIPW <br /> El Non�Metallic El Non-Metallic El Non�Metallic El Non-Metallic <br /> Method of Cathodic Protection 0 Isolation 0 Isolation M Isolation El Isolation <br /> El Other El Other El Other 0 Other <br /> (Specify in section V.) (Specify in section V) (Specify in section Vj (Specify in section V.) <br /> 10v75 10m75 10z75 <br /> Inside Diameter of Spill container: (inches) <br /> 14 14 14 <br /> Depth of Spill Container: (inches) <br /> Does the spill container have a 5 gallon capacity? M Yes El No N Yes El No N Yes 0 No El Yes El No <br /> Drain Valve M Drain Valve M Drain Valve El Drain Valve <br /> Method to Keep Spill Container Empty El Onsite Pump 0 Onsite Pump E:1 Onsite Pump E] Onsite Pump <br /> Ej Other 0 Other El Other El Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IVw SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results �Iass El Fail 0 Pass qfailj 0 Fail Fail <br /> Pass <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 /> LIST Service Technician Signature <br /> If the facility has more componendrilthan 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 />