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UNDERGROUNDSTORAGETANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action � Installation Test � Repair Test �' 12 <br />Month Test <br />1. FACILITY INFORMATION <br />CERS ID <br />Date of Spill Container Test: <br />10770799 <br />4/19/2019 <br />Business Name (Same as Facility Name or DBA -Doing Business As.) <br />7 -Eleven 38153 <br />Business Site Address <br />City: <br />Zip: <br />121 S. Center Street <br />Stockton <br />95202 <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 /># <br />Jesus Saldivar <br />(800) <br />800-4633 <br />Contractor/Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />Class A General Engineering 743160 <br />8361393 <br />6/16/2019 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />ICC - CA UST Service Technician 8361393 06/16/2019 Tanknology Certification -Level III Spill Container Testing Certification Exam 115240 <br />07/06/2019 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: Manufacturer Guidelines: (Specify) <br />r Industry Code or Engineering Standard: (Specify) PEI RP 1200 <br />I� 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 Fill T1: REGULAR Fill T2: PREMIUM Fill T3:DIESEL <br />product, etc.) UNLEADED UNLEADED Diesel <br />REG UNLEAD PREMIUM <br />Spill Container Manufacturer: OpW OPW OPW <br />� Non-Mettalic � Non-Mettalic � Non-Mettalic <br />� Non-Mettalic <br />Method of Cathodic Protection � Isolation � Isolation � Isolation <br />� Isolation <br />� Other � Other � Other <br />r Other <br />Specify in section V) (Specify in section V) (Specify in section V) <br />(Specify in section V) <br />Inside Diameter of Spill Container: 12 12 12 <br />(Inches) <br />Depth of Spill Container: (Inches) 16 16 17 <br />Does the spill container have a 5 � Yes � No � Yes � No � Yes � No <br />� Yes � No <br />gallon capacity? <br />� Drain Valve � Drain Valve � Drain Valve <br />� Drain Valve <br />Method to Keep Spill Container r Onsite Pump � Onsite Pump � Onsite Pump <br />� Onsite Pump <br />Empty � Other � Other � Other <br />� Other <br />Specify in section V) (Specify in section V) (Specify in section V) <br />(Specify in section V) <br />�/ SUMMARY OF TESTING RESULTS <br />Spill Container Test Results IX:PBSS � Fail i":P2SS � Fail !*r P2SS �` Fail <br />�P2SS 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 TECHNICIAN CONDUCTING THIS <br />hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 23, division <br />3, chapter 16, section <br />2637.1 and all the information contained herein is accurate. <br />UST Service Technician Signature <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 />