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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) Type of Action ❑ Installation Test ❑ Repair Test ❑x 12 Month Test I. FACILITY INFORMATION CERS ID Date of Spill Container Test 10063345 6/9/20 Business Name(Same as Facility Name or DBA-Doing Business As) FAST LANE GAS - DIESEL SIDE Business Site Address CityZIP Code 116 E ROTH RD LATHROP, CA 95330 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# EDWARD STEARNS (209) 744-0112 Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date 14-1760 Ex. 9/30/20 8883080-UT 11/9/2020 Spill Container Testing Training and Certifications(List applicable certifications.) III. SPILL CONTAINER TESTING INFORMATION Test Method Used: ❑x Manufacturer Guidelines(Specify): LAKE TEST ❑ Industry Code or Engineering Standard (Specify): ❑Engineered Method(Specify): Attach the testing procedures and all documentation required to determine the results. #of Attached Pages TANK ID: (By tank number,stored product, etc.) DIE SO DIE NO Spill Container Manufacturer: OPW OPW Method of Cathodic Protection: ❑x Non-Metallic 9 Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑ Isolation ❑Isolation ❑Isolation ❑Isolation ❑Other(Specify in V) ❑Other(Specify in V) ❑Other(Specify in V.) ❑Other(Specify in V) Inside Diameter of Spill Container: (Inches) 11 11 Depth of Spill Container: (Inches) 15 15 Does the spill container have a 5 gallon capacity? ❑Yes El No El Yes ❑No ❑Yes ❑No ❑Yes ❑No Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ❑Drain Valve ❑Drain Valve ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V) ❑Other(Specify in V) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results: ❑Pass ❑xFail ❑ Pass N Fail 11 ❑ Pass ❑ Fail ❑Pass ❑Fail V. COMMENTS Any items marked"Fail"above must be explained in this section. Any additional comments may also be provided here. DIESEL SOUTH IS NOT BOLTED TO SUMP LID AND DOES HOLD 5 GALLONS NEEDS REPAIR ALSO NEED TO RETEST DIESEL NORTH BUCKET AT 5 GALLONS REPAIR AND RETEST BY ELITE IV V1. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations, Title 23, Division 3, Chapter 16,Section 2637.1 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accommodates,additional copies of this page may be attached. CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council