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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Ili !I III iiiiiiiiiiiiiiiiiiiiii NON 10; wmw� <br /> Type of Action ❑ Installation Test ❑ Repair Test 12112 Month Test <br /> L FACILITY INFORMATION <br /> CERS ID Dale of Spill Container Test <br /> _ 10181235 7/ 15/2019 <br /> Business Name (Same as Facility Name or DBA -Doing Business As) <br /> Arco 5450 <br /> Business Ste Address City ZIP Code <br /> 1617 W . Fremont Stockton 195203 <br /> lie UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shokvn on the ICC Certification ) Phone # <br /> David Rouse ( 925 ) 551 - 7555 <br /> Contractor I Tank Tester License # ICC Certification it ICC Certification Expiration Date <br /> 220793 8292530 6 /28 /2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications ) <br /> OPW Tech Cert # 0108211 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used ❑ Manufacturer Guidelines (Specify) <br /> Z Industry Code or Engineering Standard (Specify) <br /> 1 Hour Hydrostatic <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 87M Fill T2 87S Fill T3 91 Fill <br /> Spill Container Manufacturer OPW OPW OPW <br /> Method of Cathodic Protection 0 Non-Metallic ❑x Non-Metallic JE Non•Melailic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V ) ❑ Other (Speci4 in V ) ❑ Other (Specify in V ) ❑ Other (Specify in V ) <br /> Inside Diameter of Spill Container (Inches) 12 12 12 <br /> Depth of Spill Container (Inches) 14 14 14 <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No 0 Yes [] No 0 Yes ❑ No © Yes ❑ No <br /> Method to Keep Spill Container Empty ® Drain Valve ( 9 Drain Valve 0 Drain Valve ❑ Drain Valve <br /> [ Onsite Pump ❑ Onsite Pump ❑ Onsile Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V ) ❑ Other (Specify in V ) ❑ Other (Speedy in V ) ❑ Other (Specify in V ) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results 0 Pass ❑ Fail Z Pass ❑ Fail (><� Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked Fad" above Hurst be explained in this section Any additional comments may also be provided here <br /> Vl . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <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 cont ' ned herein is accurate. <br /> UST Service Technician Signature <br /> /00 <br /> If the facility has more componenrAghan this form accommodates, additional copies of this page may be attached, <br /> CERS = California Environmental Reporting System, to = Identification, UST = Underground Storage Tank, ICC = International Code Caunal <br /> r <br />