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UNDERGROUND STORAGE TANK i <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test r! Repair Test 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10166017 4/22/2020 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> 7-ELEVEN #32190 , MKT 2368 <br /> Business Site Address City: Zip: <br /> 4943 S . KINGSLEY ( FRONTAGE RD) HWY 99 @ ARCH AIRPORT RD STOCKTON 95206 <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 /> Clint Fuhrman (800) 800-4633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 9160945 5/2/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW - EVR Phase 1 904272 05/23/2021 Tanknology Certification - Level III Spill Container Testing Certification Exam 96740 05/22/2022 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : r Manufacturer Guidelines : (Specify) <br /> WO-,' Industry Code or Engineering Standard : (Specify) PEI RP 1200 <br /> r 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.) Fill T4 Fill T5 Fill T6 <br /> RUL MUL PUL <br /> Spill Container Manufacturer: OPW OPW OPW <br /> r Non-Metallic Non-Metallic r Non-Metallic Non-Metallic <br /> Method of Cathodic Protection Isolation r Isolation r Isolation Isolation <br /> r Other r Other r Other r Other <br /> (Specify in section V) (Specify in section V) (Specify in section V) (Specify in section V) <br /> Inside Diameter of Spill Container: ( Inches) 12 12 12 <br /> Depth of Spill Container: ( Inches) 16 16 16 <br /> Does the spill container have a 5 gallon capacity? ryes r No r Yes r No r Yes r No r Yes r No <br /> FYI Drain Valve r Drain Valve r Drain Valve r Drain Valve <br /> Method to Keep Spill Container Empty r Onsite Pump r Onsite Pump r Onsite Pump r Onsite Pump <br /> r Other r Other r Other r Other <br /> (Specify in section V) (Specify in section V) (Specify in section V) (Specify in section V) <br /> N. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results WePass r Fail Wo Pass r Fail Rpass I Fail r7PaSS r Fail <br /> V. COMMENTS <br /> All items marked failed above must be explained in this section . Any additional comments may also be provided here . <br /> VI. CERTIFICATION BY USTSERVIGE TECHNICIAN CONDUCTING THIS <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 23 , division 3 , chapter 16 , section <br /> 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 />