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F' <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action Z Installation Test ❑ Repair Test ❑ 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180733 2/7/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Arco 7147 <br /> Business Site Address City ZIP Code <br /> 1206 E . March Lane Stockton 95210 <br /> lie UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Cartirication ) Phone # <br /> Alexander Tate ( 925 ) 551 -7555 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 220793 8296693 3/4/2019 <br /> Spill Con talner Testing Training and Certifications (List applicable certifications ) <br /> PA 00173 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used ; ❑ Manufacturer Guidelines (Specily)� <br /> Q Industry Code or Engineering Standard (Specify): Hydrostatic 1 hr . Measurements <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 91 DSL <br /> Spill Container Manufacturer: OPW Fill OPW Fill OPW Fill <br /> Method of Cathodic Protection: Qx Non-Metallic 21 Non4etallic R1 Non•Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation D Isolation ❑ isolation <br /> ❑ Other (specify in V. ) ❑ Other (Specify in V ) ❑ Other (specify in V ) ❑ Other (specify in V ) <br /> Inside Diameter of Spill Container: (inches) 12 12 12 <br /> Depth of Spill Container: (Inches) 14 14 14 <br /> Does the spill container have a 5 gallon capacity? 2 Yes ❑ No Cil Yes ❑ No Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> Q Onsite Pump 0 Onsile Pump D 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 : 2] Pass OF Pass ❑ Fail Pass ❑ Fait ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 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 /> CERS = Calibrra Environmental Repoft System, ID = Identification, UST = Underagmu r d Storage Tanto ICC = International Code Council <br />