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Jul , 2 . 2019 MRM Donlee Pump Co No . 2195 P . 8 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Test ❑ Repair Test 1@ 12 Month Test <br /> I , FACILITY INFORMATION <br /> CERS ID Date of spill Container Test <br /> 6 -28- 19 <br /> Business Name (Same as Facility Name or DESA-Doing BusinessAs.) <br /> ER VINE <br /> Business Site Address City ' ZIP Code <br /> 4733 South Hwy 99 Frontage Road Stockton <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 /> Mario Romero (209 ) 537 - 9396 Ext. 80343 <br /> ContractorfTank Tesler License # ICC Certification # ICC Certification Expiration Dale <br /> 8034353 10/13/ 19 <br /> Split Container Tesling Training and Certifications (List applicable certifications.) . <br /> OPW # 100213 <br /> III , SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ® Manufacturer Guidelines: (Specify) Hydrostatic tested <br /> D Industry Code or Engineering Standard. (S'pecif'y) <br /> ❑ Engineered Method : (Spoclfy) <br /> Attach the testing # of Attached Pages <br /> pro and all documentation to determine the results. <br /> Tank ID: (Ay tank number, stored product, etc.) Unleaded - 87 Unleaded - 01 Clear Diesel <br /> Spill Container Manufacturer: OPW OPW OPW <br /> ❑ Non-Metall►c 0 NonWatatlic ❑ Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection D Isolation D isolation 0 lsolallon ❑ Isolation <br /> D Other ❑ Other El Other D Other <br /> (saeclry In section V.) (Speciry to section v.) (Specify In section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container: (Inches) <br /> 12 t, 12t' 12° <br /> Depth of Spill Container: (Inches) 12 " 12" 2" <br /> I <br /> Does the spill container have a 6 gallon capacity? 0 Yes D No ® Yes D No ® Yes ❑ No ❑ Yes Q No <br /> j ® Drain Valve ® Drain Valve 0 Drain Valve D Drain Valve <br /> i ❑ Onsite Pump D Onsite Pump ElOnsl[e Pump D onsite Pump <br /> Method to Keep Spill Contalner Empty <br /> D Other D Other D Other D Other <br /> (Speciy in section V.) (Specify in section V) (Specify in section V.) (specify in section Y) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ® Pass ❑ Fall ® Pass ❑ Fail W Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> All items marked "Fall° above must he explained in this section. Any additional comments may Also be provided here. <br /> Replaced fill cap on diesels ill bucket, re-tested & passed good. <br /> VI . CERTIFICATION BY ' U5T SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulatlons, title 23, division 3, chapter 16, section <br /> 2637.1 and all the information contained herein Is accurate. <br /> UST Se Ice Technld;9 nature <br /> t 601irtyliasnTor co ponents than this forth accommodates, addlflonal coplas of this pago maybe attached. <br />