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20202384 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM(Page 1 of 1) <br /> Type of Action ❑Icstallation Test ❑Repair Testx❑ 12 Mon'n Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181087 8124/2020 <br /> Business Name(Samo as Facility Name or DBA-Doing Business As) <br /> Arco 2093 <br /> Business Site Address C`.ty ZIP Code <br /> 3425 Tracy Blvd Tracy 195376 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on th)iCC Cert,rcalion) Phone p <br /> Elodio Sanchez (925) 551-7555 <br /> Contractor i Tank Tester License# ICC Certification# ICC Certificat•on Expiration Date <br /> 220793 8887127 8/7/2022 <br /> Spill Container Testing Training and Certifications(List applicable cer1Xcatrons) <br /> OPW Cert# 100695 Exp. 10/24/2020 <br /> Ill. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used ❑Manufacturer Guidelines(Specify) <br /> ❑x Industry Code or Engineering Standard(Specify) <br /> 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 Vapor T2-87 Vapor T3-87 Vapor T4-87 Vapor <br /> Spill Container Manufacturer OPW OPW OPW <br /> OPW <br /> Method of Cathodic Protection Non-Metallic (]Non-Metallic ❑x Non-Metallic ❑x Non-Metallic <br /> ❑Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(Specify in V) ❑Other(Spocdy in v) ❑Other(Specify in v) ❑Other(Specify in v) <br /> Inside Diameter of Spill Container (inches) 13 13 13 13 <br /> Depth of Spill Container (Inches) 10 10 10 10 <br /> Does the spill container have a 5 gallon capacity? ❑K Yes ❑No E]Yes ❑No Q Yes ❑No [ Yes ❑No <br /> Method to Keep Spill Container Empty ❑Drain Valve ❑Drain Valve ❑Drain Valve ❑Drain Valve <br /> Onsite Pump Q Onsite Pump Q Onsite Pump Q Onsite Pump <br /> ❑Other(Specify in v) ❑Other(Specrly in v) I ❑Other(Specify in V) ❑Other(specify o v) <br /> 1V. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results Q Pass [:]Fail ❑x Pass []Fail 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 /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the spill containers were testa In accordance with California Code of Regulations, Title 23, Division 3, <br /> Chapter 16,Section 2637.1 and all the Information y9fitained,herein is accurate. <br /> UST Service Technician Signature <br /> if the facility has more componenfs than f is form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System ID=/dent f+cation UST-Underground Storage Tank.ICC=International Code Card <br />