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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 E 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181249 02/20/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> ARP MINI MART CORP <br /> Business Site Address City ZIP Code <br /> 25775 S Patterson Pass Rd Tracy 95376 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the/CC Certification.) Phone# <br /> Guadalupe Sanchez (925)470- 0803 Ext. <br /> Contractorfrank 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 /> FFS EVR Phase I Systems# 1031393709 Expires: 03/04/2022 OPW#0163755 Expires: 06/07/2021 <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 /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> Tank ID:(By tank number,stoned product,etc.) T1: 87 Slave T2: 87 Master T3: Diesel T4: 91 <br /> Spill Container Manufacturer: Phil-Tite Phil-Tate Phil-Tite Phil-Tite <br /> ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> Method of Cathodic Protection E Isolation E Isolation E 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) 11 1/4" 11 1/4" 11 1/4" 11 1/4" <br /> Depth of Spill Container.(Inches) 1711 1611 17" 1611 <br /> Does the spill container have a 5 gallon capacity? E Yes ❑No E Yes ❑No E Yes ❑No E Yes ❑No <br /> E Drain Valve E Drain Valve E Drain Valve E Drain Valve <br /> Method to Keep Spill Container Empty ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Specity 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 E Pass ❑Fail 1 E Pass ❑Fail E Pass ❑Fail E 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,a nal copies of this page may be attached. <br /> rFRc=raG6vrda FmAmn anfa!RpnnMrvi Naln.n In=klwffwalim I LST=I jmja n mri c&mww tank wr r:=Inwr=*ww r vio r w mr.8 <br />