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UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM <br />(Page 1 of 1) <br />Type of Action ❑ Installation Test ❑ Repair Test <br />X 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Spill Container Test <br />10180913 <br />1/15/2019 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />ERNIES GENERALL STORE <br />Business Site Address City <br />ZIP Code <br />4407 E WATERLOO RD STOCKTON, CA <br />95215 <br />11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN <br />INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) <br />Phone # <br />FELIX RAMIREZ <br />(209) 744-0112 <br />Contractor I Tank Tester License # <br />ICC Certification #I <br />CC Certification Expiration Date <br />08-1740 5-31-20 <br />8883072-UT <br />11/9/2020 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tile #1009883708 11/29/20 <br />OPW #104634 3-14-20 <br />III. SPILL CONTAINER TESTING INFORMATION JAW 9, 9X019 <br />Test Method Used: <br />Zx Manufacturer Guidelines (Specify): OPW LAKE TEST <br />❑ Industry Code or Engineering Standard (Specify): <br />I�;� I. <br />❑ Engineered Method (Specify): <br /># of Attached Pages <br />Attach the testing procedures and all documentation required to determine the results. <br />TANK ID: (By tank number, stored product, etc.) <br />87 <br />91 <br />DIESEL <br />Spill Container Manufacturer: <br />OPW <br />OPW <br />OPW <br />Method of Cathodic Protection: <br />X Non-Metallic <br />❑x Non-Metallic <br />❑x Non-Metallic <br />❑ Non-Metallic <br />❑ Isolation <br />❑ Isolation <br />❑ Isolation <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V.) <br />Inside Diameter of Spill Container: (Inches) <br />11 <br />11 <br />11 <br />Depth of Spill Container: (Inches) <br />13 <br />14 <br />14 <br />Does the spill container have a 5 gallon capacity? <br />❑x Yes ❑ No <br />R Yes ❑ No <br />E Yes ❑ No <br />❑ Yes ❑ No <br />Method to Keep Spill Container Empty: <br />Zx Drain Valve <br />❑x Drain Valve <br />(] Drain Valve <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Other (Specifyin V.) <br />❑ Other (Specify in V) <br />❑ Other (Specify in V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: Z Pass ❑ Fail ❑x Pass ::[::]:F ail <br />Z Pass ❑ Fail ❑ Pass ❑ Fail <br />V. COMMENTS <br />Any items marked Fail' above must be explained in this section. Any additional comments <br />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 <br />Code of Regulations, Title 23, Division 3, <br />Chapter 16, Section 2637.1 and all the information contained herein is accurate. <br />IIIIIIIIItt <br />UST Service Technician Signature <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 = International Code Council <br />