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20201392 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action Q installation Teat 0 ft"Ir Test CI 12 Month Test <br /> Is FACILITY INFORMATION <br /> CERS IG Dale of Spec Container Test <br /> 10180733 6/18/2020 <br /> &niness Name (Same as FecW Nerve orp6A&D ft Bushoss As) <br /> Arca 7147 <br /> Business Site Mdress City Zip code <br /> 1206 E March Lane I Stockton 195210 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Nome of UST Service Technician Padomettg the Test (A1rtf as shown on Me JCC Cerml anon.) Phone hf <br /> Darnell Smith (925) 551 .7555 <br /> ContractorlTaOkTester /Dene # ICC codification Ice ed1ficatlonExpirationDate <br /> 220793 8709494 11 /2312021 <br /> Spin ConWnerTesUM Tralydng and CeMcoUons (tial appUcabfo mUecatrona.) <br /> OPW Cert# 017405 Exp. 7111/2020 <br /> 111. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: 0 Manufacturer Gatdellnes (spety k <br /> M Industry code or Englneering standard (specify): Hydrostatic, OPW, Tape Measure <br /> I] Engineered Method (Spow: <br /> Attach the testing procedures and all documentation r"ulned to determine the result& S of AUadted Pages <br /> TANK ID: (Bytarftwnber, sfomdprod=4 eft) 87 Vapor T1 91 Vapor T2 DSL Va Dr T3 <br /> Sall container Manufacturer OPW OPW OPW <br /> Method of Cathodic Ptotectiat: 0 Non*Mela* C) NornMetelic ® Nan•MetaNtc 0 NonaMetatNo <br /> [3 isolation © lsaletion OlsoWlon ETI isolation <br /> ❑ otter (spew to vi 13 other Mm* o V) 0 Other M** to V.) © Other (spedry in V,) <br /> Inslde Dlanxftr of Spid Container. finches) 12 12 12 <br /> Depth of Split Container: (inches) 11112 11 112 11 112 <br /> Does the split Container have a 8 gem capacity? I@ Yes ❑ No ® Yes 13 No 0 Yes 13 No ❑ Yes 0 No <br /> Method to Keep Spill Container Empty: 0 Drain Value 13 trait Valve O Drain Valve 0 Drain Valve <br /> D Onsfte Hump M orme Pump ® 005118 Pump E7 Onsite Pump <br /> © Other (S7o.* 1n V.) I 0 011ier (&P&* Jn v) 1 0 Other (specfrytn V) 0 Other (spedyln V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill ContalnerTest Resufls: M Pass ❑ Fait I IN Pass ❑ Fait I@ Pass ❑ Fal © Pass la Fal <br /> V. COMMENTS <br /> i Anyllems marked "Fall"above must be explalned In (his sedWs Any addltww comments may also be provided here. <br /> VI* CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby cortW that the spill cordainem were tested In accordance with Cattfornta Code of Regulations, 7111119 23, Division 3, <br /> Chapter 16, Section 2637.1 and all n lag too <br /> UST Service Tec hndden Signature <br /> IV thetacfl(tyhas mwscomponents dtaaJ*.1*1hm; 4caommoCtatas, adttfdonateop192orthiapagenraybeattachad$ <br /> CERS = Carhm* EmrottnmWRepfty %4stemOnIdhuOmffort, UST= UndhYgra WgwdgeTa* CC = irdemafiorwlCodeCwld <br />