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UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 <br />of 1) <br />Type of Action � Installation Test �' Repair Test <br />� 12 Month <br />Test <br />L FACILITY INFORMATION <br />CERS ID <br />Date of Spill Container Test: <br />10166191 <br />2/6/2019 <br />Business Name (Same as Facility Name or DBA -Doing Business As.) <br />7 ELEVEN 35355 <br />Business Site Address <br />City: <br />Zip: <br />3202 W HAMMER LANE (N-136) <br />STOCKTON <br />95209 <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 />Phone # <br />Michael Deatherage <br />(800) 800-4633 <br />Contractor/Tank Tester License # <br />ICC Certification # <br />ICC Certification <br />Expiration Date <br />Class A General Engineering 743160 <br />8819901 <br />11/7/2019 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />ICC - CA UST Service Technician 8819901 11/07/2019 Tanknology Certification -Level III Spill Container Testing Certification Exam 142040 <br />03/21 /2021 <br />1111. SPILL CONTAINER TESTING INFORMATION <br />i <br />Test Method Used: �' Manufacturer Guidelines: (Specify) <br />Industry Code or Engineering Standard: (Specify) PEI RP 1200 <br />Engineered Method: (Specify) <br /># <br />of Attached Pages <br />Attach the testing procedures and all documentation required to determine the results. <br />Fill T1: <br />Fill T2: <br />Fill T3: <br />Tank ID: (By tank number, stored product, etc.) <br />RUL <br />PUL <br />Diesel <br />Spill Container Manufacturer: <br />Emco Wheaton <br />Emco Wheaton <br />Emco Wheaton <br />� Non-Mettalic <br />r Non-Mettalic <br />� Non-Mettalic <br />� Non-Mettalic <br />� Isolation <br />� Isolation <br />� Isolation <br />� Isolation <br />Method of Cathodic Protection <br />� Other <br />� Other <br />� Other <br />� Other <br />(Specify in section V) <br />(Specify in section V) <br />(Specify in section V) <br />{Specify in section V) <br />Inside Diameter of Spill Container: (Inches) <br />11 <br />11 <br />11 <br />Depth of Spill Container: (Inches) <br />15 <br />15.5 <br />15.25 <br />Does the spill container have a 5 gallon capacity? <br />� Yes � No <br />r Yes r No <br />� Yes � No <br />� Yes � No <br />� Drain Valve <br />�' Drain Valve <br />� Drain Valve <br />� Drain Valve <br />� Onsite Pump <br />r Onsite Pump <br />� Onsite Pump <br />� Onsite Pump <br />Method to Keep Spill Container Empty <br />� Other <br />� Other <br />� Other <br />� Other <br />Specify in section V) <br />(Specify in section V) <br />(Specify in section U) <br />(Specify in section V) <br />N. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results <br />r Pass � Fail <br />9" P2SS � Fail <br />Pass Fail <br />��Pass Fail <br />V. COMMENTS <br />All items marked failed above must be explained in this section. Any additional comments may also be provided here. <br />VI. CERTIFICATION BY UST SERVICE TECHNICIANICONDUCTING THIS <br />hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 23, division 3, chapter 16, section <br />2637.1 and all the information contained herein is accurate. <br />UST Service Technician Signature <br />�_ __ <br />�� <br />�,;� � .�- <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=Identification, UST=Underground storage tank, ICC=International Code Council <br />