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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 x❑ 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 1 /3/2019 <br /> Business Name (Same as Pacitity Name or DBA-Doing Business As) <br /> Arco 2186 <br /> Business Site Address City ZIP Code <br /> 3212 N California Stockton 95204 <br /> ll . 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 1 ( 925 ) 5514777 <br /> Certification Expiration Date <br /> Contractor I Tank Tester License # ICC Certification # <br /> S ill Container TeICC <br /> p 2207930 8292530 6/28/2020 <br /> Testing Training and Certifications (List applicable certifications. ) <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used ❑ Manufacturer Guidelines (Specify). <br /> 0 industry Code or Engineering Standard (Specify) Hydrostatic Tape Measure <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 - Unleaded T1 - Unleaded T2-Unleaded T3- Premium <br /> Spill Container Manufacturer OPW Vapor OPW- Vapor OPW- Vapor OPW- Vapor <br /> Method of Cathodic Protection ❑x Non-Metallic 9 NonWetallic 0 Non-Metallic 0 NonWetallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V ) ❑ Other (Specify in V ) ❑ Other (Specify in V ) ❑ Other (specify in V ) <br /> Inside Diameter of Spill Container; (Inches) 11 1 /2" 11 112" 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? 21 Yes ❑ No 0 Yes ❑ No 2 Yes ❑ No [j] Yes ❑ No <br /> Method to Keep Spill Container Empty ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> Q Onsite Pump 0 Onsite Pump n Onsile Pump (] Onsite Pump <br /> ❑ Other (Specify in V ) ❑ Other (Specify in V ) ❑ Other (Specify in V ) ❑ Other (Specify in V ) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : =ass ❑ Fail I (] Pass ❑ Fail N Pass ❑ Fail O Pass ❑ 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 /> i <br /> i <br /> I <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 Informatl9p con ed herein is accurate. <br /> UST Service Technician Signature <br /> if the facility has more component an this form accommodates, additional copies of this page may be attached. <br /> CERS = Cakfomfa Environmental Reporting System. ID = Identification, UST = Underground Storage Tank, ICC = Intemalional Code Courd <br /> i <br />