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20202384 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page i of i) <br /> Type of Action ❑Installation Test ❑Repair Test 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Dale of Spill Container Test <br /> 10181087 8/24/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Arca 2093 <br /> Business Site Address City ZIP Code <br /> 3425 Tracy Blvd Tracy 95376 <br /> III. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification) <br /> 7�;� <br /> Elodio Sanchez <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 220793 8887217 8/7/2022 <br /> Spill Container Testing Training and Certifications(List applicable certifications) <br /> OPW Cert# 100695 Exp. 10124/2020 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used ❑Manufacturer Guidelines(Specify) <br /> x❑Industry Code or Engineering Standard(Specify) Hydrostatic, OPW, Tape Measure <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) T1-87 FIII T2-87 Fill T3-87 Fill T4-91 Fill <br /> Spill Container Manufacturer OPW OPW OPW OPW <br /> Method of Cathodic Protection ❑x Non-Metallic Non-Metallic F1 Non-Metallic 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 Spilt Container (inches) 13 13 13 13 <br /> Depth of Spilt Container(inches) 10 10 10 10 <br /> Does the spill container have a 5 gallon capacity? 2 Yes ❑No 2 Yes ❑No Yes ❑No H Yes ❑No <br /> Method to Keep Spill Container Empty ❑x Drain Valve x <br /> ❑Drain Valve Q Drain Valve Q Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in V) []Other(Speciy m V) I ❑Other(Specify in V) ❑Other(Specify in V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ❑x Pass ❑Fail I ❑x Pass ❑FailPass x <br /> ❑ ❑Fail ❑x Pass E3 Fail <br /> V. COMMENTS - . <br /> Any items marked"Fait"above must be explained in this section Any additional comments may pr0&ed <br /> r- _ � ;' <br /> SEP 11 2020 <br /> ENVIRONMENTAL DEALT <br /> Vl. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the spill containers were taste in accordance with California Code of Regulations, Title 23, Division 3, <br /> Chapter 16,Section 2637.1 and all t Information tains herein is accurate. <br /> UST Service Technician Signature <br /> 4�4 -.0" <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=California Envmnmerttal Reporting System ID=Identification UST=Underground Storage Tank.ICC=International Code Council <br />