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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 /> 10186687 3 /25/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> CA Gasoline Inc <br /> Business Site AddressCity ZIP Code <br /> 2115 West Yosemite Ave Manteca 95337 <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 /> Anthony Reyes 1 (916 ) 372 - 1885 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 617238 8293772 9/ 16/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW Tech# 103920 , PhikTite Tech# 1003213709 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify) : Lake Test <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 tanknumber, storedproduct, etc.) 87 Gasoline 91 Gasoline Diesel 87 .2 Gasoline <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑x Isolation ❑x Isolation M Isolation 9 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 . 5 11 . 5 11 . 5 11 . 5 <br /> Depth of Spill Container: (Inches) 15 . 5 16 15 15 . 5 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑x Yes ❑ No ❑x Yes ❑ No ❑x Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve 0 Drain Valve 0 Drain Valve 9 Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> [E] Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specifyin V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: IE Pass ❑ Fail ❑Q Pass ❑ Fail 9 Pass ❑ Fail ❑x Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail' above must be explained in this section. Any additional comments may also be provided here . <br /> 87 fill sump is a "four pack" style , where there are two fill spill containers for the same tank . <br /> P 0 3 2020 <br /> ENVIRON MENTAaL iE,"-', LTH <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING 11HISI EST ING <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 = Cal'ifornia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Coundl <br />