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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action 0 Installation Test 0 Repair Test Q 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 1 /3/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Arco 2186 <br /> Business Site Address City ZIP Code <br /> 3212 N California Stockton 95204 <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 /> David Rouse ( 925 )5514777 <br /> Contractor 1 Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> p I Container Te2207930 8292530 6/28/2020 <br /> NIA sting Training and Certifications (List applicable certifications) <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : 0 Manufacturer Guidelines (Specify): <br /> 91 Industry Code or Engineering Standard (Specify) : Hydrostatic, Tape Measure <br /> 0 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 - Unleaded T1 - Unleaded T2-Unleaded T3- Premium <br /> Spill Container Manufacturer: OPW- Vapor OPW- Vapor OPW Vapor OPW- Vapor <br /> Method of Cathodic Protections 0 Non- Metallic [—Jx Non-Metallic x0 NonWetallic Cx Non-Metallic <br /> 0 Isolation 0 Isolation 0 isolation 0 Isolation <br /> ❑ Other (Specify in v ) 0 Other (Specify in V ) ❑ Other (Specify in v) 0 Other (Specify in v ) <br /> Inside Diameter of Spill Container (Inches) 11 1/2" 11 1 /2" 11 1 /2" 11 1 /2" <br /> Depth of Spill Container (Inches) 12" 12" 12" 12" <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No El Yes EI No 0 Yes 0 No Yes 0 No <br /> Method to Keep Spill Container Empty4 0 Drain Valve 0 Drain Valve 0 Drain Valve 0 Drain Valve <br /> Cx Onsite Pump 0 Onsite Pump El Onsite Pump Cx Onsite Pump <br /> 0 Other (specify in v ) 0 Other (specify in V ) 0 Other (Specify in v ) 0 Other (Specify in v ) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results Pass 0 Fail 0 Pass ❑ Fail Cx Pass 0 Fail [x Pass 0 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 tested In accordance with California Code of Regulations, Title 23, Division 3 , <br /> Chapter 16, Section 2637 .1 and all the Informationgontalpo herein is accurate. <br /> UST Service Technician Signature <br /> ff the facility has more components tj this dorm accommodates, additional copies of this page may be attached. <br /> CERS = Caftnia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council <br /> I <br /> 4 <br />