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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Action F1Installation Test ElRepair Test 12 Month Test I . FACILITY INFORMATION CERS ID Date of Spill Container Test 10181351 12 /03/2018 Business Name (Same as Facility Name or DBA-Doing Business As) Fast & Easy # 103 Business Site Address City ZIP Code 8660 Lower Sacramento Road Stockton 95212 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # A ( 800 ) 339-9930 ustin Sterling Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 804904 8339953 3 /27/2019 Spill Container Testing Training and Certifications (List applicable certifications.) OPW 104049 R E I D III . SPILL CONTAINER TESTING INFORMATION Test Method Used : ❑ Manufacturer Guidelines (Specify) : D 5fl Industry Code or Engineering Standard (Specify) : PEI 1200 ENVIRONMENTAL HEALTH ❑ Engineered Method (Specify) : DEPARTMENT # of Attached Pages 1 Attach the testing procedures and all documentation required to determine the results. TANK ID : (By tank number, stored product, etc.) Regular Premium Diesel Spill Container Manufacturer: Opw 7Opw OPw Method of Cathodic Protection : ❑x Non- Metallic ❑x Non-Metallic ❑x Non-Metallic ❑ Non-Metallic ❑ Isolation ❑ 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 . 00" 12. 00" 12.00" Depth of Spill Container: (Inches) 12. 00" 12. 00" 12 . 00" Does the spill container have a 5 gallon capacity? LE10ther ❑ No ❑x Yes ❑ No (] Yes ❑ No [:1 Yes ❑ No Method to Keep Spill Container Empty: Valve ❑x Drain Valve ❑x Drain Valve ❑ Drain Valve e Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : Q Pass El F : X Pass ❑ Fail ❑Q 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 Coundl 111 - Rev. 06/14/18 UN -108 www. unidocs. org