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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Test ❑ Repair Test ❑x 12 Month Test <br /> L FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181239 2 / 14/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> A&A GAS <br /> Business Site Address City ZIP Code <br /> 16 E . HARDING WAY STOCKTON , CA 95203 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> EDWARD STEARNS (209) 744-0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 9/30/20 888308MT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 1009893708 Ex. 11 /29/2020 <br /> OPW # 104-635 Ex. 3/14/2020 <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 /> # 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.) 87 87 DIESEL 91 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: Non-Metallic Z Non-Metallic ❑x Non-Metallic N Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Othe73i <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches)Depth of Spill Container: (Inches) 13 13 13 <br /> Does the spill container have a 5 gallon capacity? 2 Yes ❑ No ❑x Yes ❑ No ❑x Yes ❑ No R Yes ❑ No <br /> Method to Keep Spill Container Empty: 9 Drain Valve N Drain Valve x Drain Valve ❑ Drain Valve <br /> r ❑ 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 : Z Pass ❑ Fail I Z Pass ❑ Fail Pass ❑ Fail 9 Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" above must be explained in this section. Any additional com %enls rtay Iso be prouided( ere <br /> v_Ei V <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTIlkd THIS TESTING <br /> I 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 <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> I <br /> International Code Counal <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = <br /> i <br /> I <br />