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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Test ❑Repair Test ❑x 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180851 5/6/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> COUNTRY MART GAS <br /> Business Site Address City ZIP Code <br /> 34243 S CHRISMAN RD ITRACY, CA 95376 <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 /> ZANE NIMMO (209) 744-0112 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 04-1676 Ex. 3/31/22 1 8883064-UT 6/1/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> Franklin Fueling - EBW& Phil Tite #10009843708 Ex.11/29/2020 <br /> OPW#104-632 Ex. 3/15/2022 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): O P W PHASE I LAKE TESTING <br /> ❑ Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> # <br /> Attach the testing procedures and all documentation required to determine the results. of Attached Pages <br /> TANK ID:(By tank number,storedproduct,etc.) 87 OCTANE 91 OCTANE DIESEL 4 K DIESEL 12K <br /> Spill Container Manufacturer: O P W O P W O P W O P W <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic ❑x Non-Metallic ❑x Non-Metallic <br /> ❑ Isolation ❑Isolation ❑ Isolation ❑Isolation <br /> ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container:(Inches) 11 1/2 11 1/2 11 1/2 11 1/2 <br /> Depth of Spill Container:(Inches) 13 13 14 14 <br /> Does the spill container have a 5 gallon capacity? I]Yes ❑No 0 Yes ❑No El Yes ❑ No Yes ❑No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve x Drain Valve (x Drain Valve ❑x Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in V.) ❑Other(Specify in V) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑x Pass ❑ Fail Z Pass El=Fail Pass ❑Fail ❑x Pass ❑Fail <br /> V. COMMENTS <br /> Any items marked"Fail"above must be explained in this section. Any additional comment ptsd die provided here. <br /> I IL 1® Nk." V , C, <br /> MAY 18 2020 <br /> r101/10r)KIlt CNITA,,1 !-FALTH <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 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=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br />