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20201392 UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Adlon ❑ Installation Test ❑ Repair Test M 12 Month Test I. FACILITY INFORMATION CERS ID Date of Spill Container Test 10180733 6/18/2020 Business Name (Same as Facility Name or DBA-Doing Business As) Arco 7147 Business Site Address City ZIP Code 1206 E March Lane Stockton 195210 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the iCC Certification) Phone # Darnell Smith (925) 5514555 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 220793 8709494 11 /23/2021 Spill Container Testing Training and Certifications (List applicable certifications.) OPW Cert# 017405 Exp. 7/11 /2020 III. SPILL CONTAINER TESTING INFORMATION Test Method Used: [I Manufacturer Guidelines (Specify): (] Industry Code or Engineering Standard (Specify): © PW Tape a Measure p ❑ Engineered Method (Spedly): j Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK ID: (By tank number, stored product, etc.) 87 Fill T1 87 Fill T2 DSL T3 Spill Container Manufacturer. OPW OPW OPW Method of Cathodic Protection: ❑ Non-Metallic ❑ NonWetallic ❑ Non-Metallic ❑ Non-Metallic CO Isoiation 21 Isolation CI Isolation ❑ Isolation ❑ Other (specify in V.) ❑ Other (Spadly In V.) ❑ Other (Specify in v.) ❑ Other (Specify in V.) Inside Diameter of Spill Container, (inches) 12 12 12 Depth of Spill Container. (inches) 11 1 /2 11 1 /2 11 1 /2 Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No CI Yes [] No M Yes ❑ No ❑ Yes ❑ No Method to Keep Spill Container Empty: ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve 0 Onsite Pump O Onsite Pump 91 Onsite Pump ❑ Onsite Pump ❑ Other (Specify to v) ❑ Other (specify in v.) ❑ Other (specify in v.) ❑ Other (specify In v.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results: d Pass ❑ Fail p Pass ❑ Fall O Pass ❑ Fall ❑ Pass ❑ Fail V. COMMENTS Any items marked Tall" 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 1nf 1ne in la accurate, UST Service Technician Sign >00 atureeor 7 r If the facility has more components than thtrformaCcominadates, addiUonat copies of this page may be attached. CERS = Cdw is Emi onmental Repotting System, ID = Idettkabm UST = Undagmund Storage Tank, ICC = hemational Code Council