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UNDERGROUND STORAGETANK NOUN <br /> SPILL CONTAINER TESTING REPORT FORM(Page I of 1) <br /> Type of Action Installation Test [I Repair Test E3 12 Month Test <br /> I. <br /> CERS ID FACILITY INFORMATION Date of Spill Container Test <br /> Business Name(Same as Facility Name or DBA-Doing Busirta�iziAs) 11/9/2018 <br /> Waterloo Food & Fuel <br /> Business Site Address city ZIP Code <br /> 3032 Waterloo Rd Stockton 195205 <br /> T <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of LIST Service Technician Performing the Test(Print as shown on the/cc Certification.) Phone# <br /> Ronnie Lewis (916) 382-4761 <br /> Contractor/Tank Tester License# ICG Certification# ICC certification Expiration Date <br /> 949066 8032737 7/6/2019 <br /> Spill Container Testing-Training and Certifications(Ust applicable certifications.) <br /> OPW, Franklin Fueling, [CC Service Tech and Tank Installer <br /> M r1mu&4"% 1 It 41, <br /> SPILL CONTAINER TESTING INFORMATIO <br /> Test Method Used: 0 manufacturer Guidelines(speciry): <br /> [91 Industry Code or Engineering Standard(Specify): INUV <br /> 1 hour Lake Test with water <br /> [3 Engineered Method(Specify): <br /> ENVIRONMENTAL HEA <br /> Attach the testing procedures and all documentation required to determine the results. MENT <br /> TANK ID:(By tank number,stored product,etc.) 87 <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection: nx Non-Metallic 0 Non-Metallic C]Non-Metallic 0 Non-Metallic <br /> 0 Isolation 0 Isolation 0 Isolation El Isolation <br /> [3 Other(specify in v) EI Other(specify in v) [I Other(Specify in V.) [I Other(Specify in v) <br /> Inside Diameter of Spill Container:(Inches) 11 a <br /> Depth of Spill Container.(Inches) 15" <br /> Does the spill container have a 5 gallon capacity? 91 Yes No 0 Yes 0 No 0 Yes 0 No [I Yes ❑No <br /> Method to Keep Spill Container Empty: I@ Drain Valve [I Drain Valve 171 Drain Valve 0 Drain Valve <br /> 0 Onsite Pump n Onsite Pump 0 Onsite Pump El Onsite Pump <br /> I []other(specify in v) 1 0 Other(specify in v) 171 Other(specify in v.) 171 Other(Specify in v) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: 9 Pass [I Fail I El Pass [I Fail. 0 Pass D Fail 0 Pass [I Fail <br /> V. COMMENTS <br /> Any items marked Fall"above must be explained in this section. Any additional comments may also be provided here. <br /> Replaced defective spill bucket and tested.All pass. <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, <br /> -Chapter IS,Section 2637.1 and all the Information contained herein Is accurate. <br /> LIST Service Technician Signature <br /> if the facility has more components than this form accommodates,aWitforlal COPISS Of this page may be attached. <br /> CERS=Callbria Bwwnenlal Reporting SyskM ID=Idenftation,UST= Tank ICC=ky"national Code Courd <br />