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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 E 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10182243 03/12/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> MAIN STREET ARCO AM PM <br /> Business Site Address City ZIP Code <br /> 1100 S Main St 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 /> Guadalupe Sanchez (925)470 - 0803 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1005444 5250451 04/05/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> FFS EVR Phase I Systems# 1031393709 Expires: 03/04/2022 OPW#0163755 Expires: 06/07/2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑Manufacturer Guidelines:(Specify) <br /> E Industry Code or Engineering Standard:(Specify) PEI/RP1200-17 <br /> ❑Engineered Method:(Specify) <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages3 <br /> Tank ID:(By tank number,stored product,etc.) T1: 87 West T1: 87 East T2: 91 T3: 89 <br /> Spill Container Manufacturer. OPW OPW OPW OPW <br /> ❑ Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> Method of Cathodic Protection E Isolation E Isolation E Isolation E Isolation <br /> ❑Other ❑Other ❑Other ❑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) <br /> 11" 11" 11" 11" <br /> Depth of Spill Container:(Inches) 13 3/4" 14 3/4" 14 3/4" 14 1/4" <br /> Does the spill container have a 5 gallon capacity? E Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> E Drain Valve E Drain Valve E Drain Valve E Drain Valve <br /> Method to Keep Spill Container Empty ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Specify in section V.) (Specify in section V) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ®Pass ❑ Fail E Pass ❑Fail E Pass ❑Fail E Pass ❑ Fail <br /> V. COMMENTS <br /> All 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 tested In accordance with Califomia 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 forma commodates,additional copies of this page may be attached. <br /> ('.FRC=ralifnmia Fnvinvnnanfal RannMrv,%,.,s in a WarmRr-l I LST e I Irviarnrry M etr r tank IrYr a intr, aH,v,a1 r.via r v vv-Ai <br />