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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Test ❑ Repair Test Z 12 Month Test I . FACILITY INFORMATION CERS ID Date of Spill Container Test 10180695 7/ 1 /2019 Business Name (Same as Facility Name or DBA-Doing Business As) Quik Stop Market #76 Business Site Address City ZIP Code 1030 S . Olive Ave Stockton 95215 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # Max Hines , Paul Wright ( 916 ) 372 - 1885 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 617238 8750053 11 /9/2019 Spill Container Testing Training and Certifications (List applicable certifications.) OPW , PhikTite III . SPILL CONTAINER TESTING INFORMATION Test Method Used : Z Manufacturer Guidelines (Specify) : ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) 87 91 Spill Container Manufacturer: OPW OPW Method of Cathodic Protection : ❑ Non-Metallic ❑ Non-Metallic ❑ Non- Metallic ❑ Non-Metallic ❑x Isolation Z Isolation ❑ Isolation ❑ Isolation ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) Inside Diameter of Spill Container: (Inches) 12 12 " Depth of Spill Container: (Inches) 15 15 it Does the spill container have a 5 gallon capacity? El Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ❑ Drain Valve ❑ Drain Valve ❑x Onsite Pump ❑x Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) ❑ Other (Specify in V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : 0 Pass ❑ Fail Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail' 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 information contained herein is accurate. UST Service Technician Signature If the facility has more components 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