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If the facility has more components than this form accommodates, additional copies of this page may be attached. <br />CERS = California Environmental Reporting System, ID = Identfication, UST =Underground Storage Tank, ICC = International Code Council <br />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 <br />10181259 <br />Date of Spill Container Test <br />3/27/2019 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />AJ's SINCLAIR MINI MART <br />Business Site Address City <br />7906 N. EL DORADO STREET STOCKTON, CA <br />ZIP Code <br />95210 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) <br />ZANE NIMMO <br />Phone # <br />(209) 744-0112 <br />Contractor / Tank Tester License # <br />04-1676 Ex. 3/31/19 <br />ICC Certification # <br />8883064-UT <br />ICC Certification Expiration Date <br />6/1/2019 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tite #10009843708 Ex.11/29/2020 <br />OPW #104-632 Ex. 3/14/2020 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />❑x Manufacturer Guidelines (Specify): O P W PHASE I LAKE TESTING <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />_of <br />Attach the testing procedures and all documentation required to determine the results. 7# <br />Attached Pages <br />TANK ID: (By tank number, stored product, etc.) <br />1 - 87 OCT <br />2 - 87 SLAVE <br />3 - 87 SYPHON <br />4 - 91 OCT <br />Spill Container Manufacturer: <br />O P W <br />O P W <br />O P W <br />Method of Cathodic Protection: <br />❑x Non-Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑x Non-Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑x Non-Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑x Non-Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />Inside Diameter of Spill Container: (Inches) <br />11 <br />11 <br />11 <br />11 <br />Depth of Spill Container: (Inches) <br />13 <br />13 <br />13 <br />13 <br />Does the spill container have a 5 gallon capacity? <br />❑x Yes ❑ No <br />❑X Yes ❑ No <br />❑x Yes ❑ No <br />0 Yes ❑ No <br />Method to Keep Spill Container Empty: <br />❑x Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V) <br />N Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specifyin V.) <br />x Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />(x Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: <br />❑Q Pass E] Fail x❑ Pass ❑Fail <br />Pass ❑ Fail <br />0 Pass ❑ Fail <br />V. COMMENTS <br />Any items marked "Fail" above must be explained in this section. Any additional comment may also be provided here. <br />ALL SPILLS CONTAINED IN FILL SUMPS W/ SENSORS <br />ALL BUCKETS MEASURED 5 GALLONS <br />ENVIRONMENTAL HEALTH <br />DEP,,/\ i 4s <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 information contained herein is accurate. <br />UST Service Technician Signature <br />If the facility has more components than this form accommodates, additional copies of this page may be attached. <br />CERS = California Environmental Reporting System, ID = Identfication, UST =Underground Storage Tank, ICC = International Code Council <br />