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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Pagel of 1) <br /> Type of Action ❑Installation Test ❑Repair Test Z 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180695 7/2/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Quik Stop Market #76 <br /> Business Site AddressCity ZIP Code <br /> 1030 S Olive Ave Stockton 95215 <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 /> Anthony Reyes (916) 372-1885 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 617238 8293772 9/16/2020 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW Tech#103920, Phil-Tite Tech#1003213709 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): Lake Test <br /> ❑Industry Code or Engineering Standard(Specify): <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.) 87 Gasoline 91 Gasoline <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> 0 Isolation x❑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) 11.5 11.5 <br /> Depth of Spill Container:(Inches) 15 15 <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑No 0 Yes ❑No ❑Yes ❑No ❑Yes ❑ No <br /> Method to Keep Spill Container Empty: 0 Drain Valve Cx Drain Valve ❑Drain Valve ❑Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite 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: 9 Pass El=Fail Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑Fail <br /> V. COMMENTS <br /> Any items marked"Fail'above must be explained in this section. Any additional comments may ide` 'WED <br /> JUL 0 9 2020 <br /> ENVIRONMENTAL HEALTH <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING TH <br /> 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 n <br /> If the facility has more components than this form accommodates,additional copies of this page maybe attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=Intemational Code Coundl <br />