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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ► Type of Action ❑ Installation Test ❑ Repair Test 2112 Month Test I . FACILITY INFORMATION CERS ID Dale of Spill Container Test 10181235 7/ 15/2019 Business Name (Same as Facility (lame or DSA &Doing Business As) Arco 5450 Business Site Address City ZIP Code 1617 W . Fremont Stockton 95203 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification 1 Phone # David Rause (925 ) 551 -7555 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 220793 8292530 6/28/201 .9 Spill Container Testing Training and Certifications (List applicable certifications ) OPW Tech Cert #0108211 Ili. SPILL CONTAINER TESTING INFORMATION Test Method Used ❑ Manufacturer Guidelines (Specify) El Industry Code or Engineering Standard (Specify) 1 Hour Hydrostatic ❑ Engineered Method (Specify) Attach the testing procedures and all documentation required to determine the results. I # of Attached Pages r TANK ID: (By tank number, storedprnduct. etc ) T1 87M Vapor T2 87S Vapor T3 91 Vapor Spill Container Manufacturer OPW OPW OPW Method of Cathodic Protection ❑x Non-Metallic ❑x Non,Melallic 0 Non-Metallic ❑ Non-Metallic ❑ Isolation ❑ isolation ❑ Isolation ❑ Isolation ❑ Other (Spectly in V ) ❑ Other (specify in V ) ❑ Other (Specify in V ) ❑ other (Specify in V ) Inside Diameter of Spill Container (Inches) 12 12 12 Depth of Spill Container (Inches) 14 14 14 Does the spill container have a 5 gallon capacity? El Yes ❑ No i] Yes ❑ No El Yes ❑ No ❑ Yes ❑ No Method to Keep Spill Container Empty ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve 21 Onsite Pump 0 Onsite Pump ® Onsite Pump ❑ Onsite Pump ❑ Other (Specify in v ) ❑ Other (Speedy in V ) ❑ Other (Specify in V ) ❑ Other (Specify in v ) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results E) Pass ❑ Fail ❑x Pass ❑ Fail (9 Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fart" above must be explained in this section Any additional comments may also be provided here VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations , Title 23, Division 3 , Chapter 16 , Section 2637 . 1 and all the inform tion tained herein is accurate. UST Service Technician Signature It the facility has more compon nts than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System. ID = Identification, UST = Underground Storage Tank, ICC = International Code Council