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UNDERGROUND STORAGE TANK.. <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action � Installation Test r' Repair Test 12 <br />Month Test <br />1. FACILITYINFORMATION <br />CERS ID <br />10770799 <br />Date of Spill Container Test: <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 />121 S. Center Street <br />City: <br />Stockton <br />Zip: <br />95202 <br />II. UNDERGROUND STORAGE TANKSERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) <br />Jesus Saldivar <br />Phone <br />(800) <br /># <br />800-4633 <br />Contractor/Tank Tester License # <br />Class A General Engineering 743160 <br />ICC Certification # <br />8361393 <br />ICC Certification Expiration Date <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 />f+/, Industry Code or Engineering Standard: (Specify) PEI RP 1200 <br />Engineered Method: (Specify) <br />Attach the testing procedures and all documentation required to determine the results. <br /># of Attached Pages <br />Tank ID: (ey tank number, stored <br />product, etc.) <br />Fill T1: REGULAR <br />UNLEADED <br />REG UNLEAD <br />Fill T2: PREMIUM <br />UNLEADED <br />PREMIUM <br />Fill T3:DIESEL <br />Diesel <br />Spill Container Manufacturer: <br />OPW <br />OPW <br />OPW <br />Method of Cathodic Protection <br />�' Non-Mettalic <br />� Isolation <br />� Other <br />(Specify in section V) <br />� Non-Mettalic <br />� Isolation <br />r Other <br />(Specify in section V) <br />� Non-Mettalic <br />r Isolation <br />� Other <br />(Specify in section V) <br />� Non-Mettalic <br />� Isolation <br />� Other <br />(Specify in section V) <br />Inside Diameter of Spill Container: <br />(Inches) <br />12 <br />12 <br />12 <br />16 <br />16 <br />17 <br />Depth of Spill Container: (Inches) <br />� Yes � No <br />�' Yes � No <br />� Yes � No <br />� Yes � No <br />Does the spill container have a 5 <br />gallon capacity? <br />� Drain Valve <br />� Onsite Pump <br />� Other <br />(Specify in section V) <br />r Drain Valve <br />� Onsite Pump <br />� Other <br />(Specify in section V) <br />� Drain Valve <br />� Onsite Pump <br />� Other <br />(Specify in section V) <br />� Drain Valve <br />� Onsite Pump <br />� Other <br />(Specify in section V) <br />Method to Keep Spill Container <br />Empty <br />SUMMARY OF TESTING RESULTS <br />�, <br />,Pass � Fail <br />P"'€P2SS � Fail <br />!�' P2SS � Fail <br />I sPBSS Fail <br />Spill Container Test Results <br />U COMMENTS <br />All items marked failed above must be explained in this section. Any additional comments may also be provided here. <br />VI. CERTIFtCAT10N BY UST SERVICE TECHNICIAN CONDUCTING THIS <br />1 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 />d�"" �.,��.: <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 />