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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 /> 10181511 07/29/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> KwikSery #98 <br /> — ------ - <br /> Business Site Address City 1 - ZIP Code <br /> 2501 Jackson Ave. Escalon 4 95320 — <br /> I <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION_ <br /> Name of UST Service Technician Performing the Test (Print as shown on the iCC Certification.) — i Phone # -- —� <br /> Brian McPheely (408 ) 971 -2445 <br /> Contractor / Tank Tester License # i ICC Certification # ! ICC Certification Expiration Date <br /> 485184 8822062 11 )9/19 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 1014303708 / 104773 <br /> ilia SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ® Manufacturer Guidelines (Specify): OPW <br /> I <br /> ® Industry Code or Engineering Standard (Specify) : PEI 1200 <br /> ! ❑ 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 product, etc,) 1 Regular k 2 Prern 3 Diesel 4 <br /> Spill Container Manufacturer. EBW r Philtite OPW <br /> Method of Cathodic Protection : <br /> ® Non-Metallic 1 ® Hon-Metallic ® Hon-Metallic — El Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ isolation ❑ Isolation I <br /> ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (specify in V.) <br /> Inside Diameter of Spill Container: (inches) 13 12 12 <br /> Depth of Spill Container: (inches) 15 115 11 a I <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No - © Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: QJ Drain Valve ® Drain Valve ® Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> = r <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify <br /> IV, SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ® Pass ❑ Fail ® Pass ❑ Faii ; ® Pass ❑ Fail ❑ Pass ❑ Fail 6 <br /> V, COMMENTS <br /> Any items marked 'Fail" above must be explained in this section. Any additional comments may also be provided here. <br /> i <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 16 , Section 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 = Calitorrua Environmental Reporting System, ID = Identitication, UST = Underground Storage Tank ICC = International Code Council <br /> I <br /> 4E! <br /> E <br />