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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑installation Test ❑Repair Test ® 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10746523 02/19/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Pershing Holdings Inc. <br /> Business Site Address City ZIP Code <br /> 1329 Escalon Ave. Escalon 95320 <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 /> Guadalupe Sanchez (925)470- 0803 Ext <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1005444 5250451 04/05/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW#0163755 Expires: 06/07/2021 FFS EVR Phase I Systems# 1031393709 Expires: 03/04/2022 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑Manufacturer Guidelines:(Specify) <br /> ®Industry Code or Engineering Standard:(Specify) PEI/RP1200-17 <br /> ❑ Engineered Method:(Specify) <br /> #of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> Tank ID:(By tank number,stored product,etc.) T1: 87 South T1: 87 North T2: 911 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> Method of Cathodic Protection ®Isolation ®Isolation ®Isolation ❑Isolation <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container.(inches) <br /> 11" 11" 11" <br /> Depth of Spill Container(inches) 14 1/4" 14" 14 3/4" <br /> Does the spill container have a 5 gallon capacity? ®Yes ❑No ESI Yes ❑No ®Yes ❑No ❑Yes ❑ No <br /> ®Drain Valve ®Drain Valve ®Drain Valve ❑Drain Valve <br /> Method to Keep Spill Container Empty ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ®Pass ❑ Fail 11 ®Pass ❑Fai1 ®Pass ❑Fail 1 ❑Pass ❑Fail <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 /> UST Service Technician Signature <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> r.FRC=ra16vn1a Fnvfnvvn rdal RPrv%M n.%,.. m in=kw twraNrvt I LQT=I bwipmnw m etrvxn tank tri.=jmpnu wv,al r W r v am <br />