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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM(Page 1 of 1) <br /> Type of Action I- Installation Test F Repair Test W 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10770799 4/23/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> 7-Eleven 38153 <br /> Business Site Address City: Zip: <br /> 121 S.Center Street Stockton 95202 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> Erik Mcallister (800)800-4633 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Class A General Engineering 743160 9122530 4/17/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> ICC-CA UST Service Technician 9122530 04/17/2021 OPW-EVR Phase 1 0178150 05/23/2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: F Manufacturer Guidelines: (Specify) <br /> W Industry Code or Engineering Standard: (Specify) PEI RP 1200 <br /> r Engineered Method: (Specify) <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> Tank ID: (By tank number, stored Fill T1: REGULAR Fill T2: PREMIUM Fill T3:DIESEL <br /> product, etc.) UNLEADED UNLEADED Diesel <br /> REG UNLEAD PREMIUM <br /> Spill Container Manufacturer: OPW OPW OPW <br /> r Non-Metallic r Non-Metallic r Non-Metallic Non-Metallic <br /> Method of Cathodic Protection r Isolation F Isolation r Isolation I- Isolation <br /> r Other r Other r Other r Other <br /> Specify in section V) (Specify in section V) (Specify in section V) (Specify in section V) <br /> Inside Diameter of Spill Container: 12 12 12 <br /> (Inches) <br /> Depth of Spill Container: (Inches) 19 17 17 <br /> Does the spill container have a 5 r Yes r No r Yes r No W Yes r No 1—Yes r No <br /> gallon capacity? <br /> r Drain Valve r Drain Valve W Drain Valve r Drain Valve <br /> Method to Keep Spill Container r Onsite Pump r Onsite Pump r Onsite Pump r Onsite Pump <br /> Empty r Other r Other r Other r Other <br /> Specify in section V) (Specify in section V) (Specify in section V) (Specify in section V) <br /> N, SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results I�'P2SS r Fail I�'Pass r Fail 1�P2SS Fail rPass Fail <br /> V. COMMENTS <br /> All items marked failed above must be explained in this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> 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,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 />