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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (page 1 of 1 ) <br /> FTyof Action 0 installation Test ❑ Repair Test ® 12 ;Montthst <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10746523 2/19/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Pershing Holdings Inc. <br /> Business Site Address City ZIP Code <br /> 1329 Escalon Ave . Escalon 95320 <br /> 11, UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the /CC Certification.) Phone # <br /> Guadalupe Sanchez (925) 470 - 0803 Ext. <br /> Contractorfrank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1005444 5250451 4/8/2019 <br /> Spill Container Testing Training and Certifications (Ust applicable certifications.) <br /> OPW #0163755 Expires: 6/ 18/2019 FFS EVR Phase I Systems # 1031393709 Expires: 3/4/2020 <br /> Ill. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑ Manufacturer Guidelines: (Specify) <br /> ® Industry Code or Engineering Standard: (Specify) PEI/R!31200-17 <br /> ❑ Engineered Method: (Specify) <br /> Attach the testing procedures and all documentation required to determine the results. # ofAttached Pages <br /> Tank ID: (By tank number, stored product, etc.) T1 : 87 South T1 : 87 North T2: 91 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> ❑ Non-Metallic ❑ Non-Metallic ❑ Non•Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection ® Isolation ® Isolation ® Isolation ❑ Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> 11 <br /> Inside Diameter of Spill Container: (inches) " 11 " 11 " <br /> Depth of Spill Container. (Inches) 131 /4 131 /8 141 /8 <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No <br /> 19 Drain Valve ® Drain Valve 10 Drain Valve ❑ Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify /n section V.) (Specl fy In section V.) (Specify in section V.) <br /> N. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> All items marked `Fall" 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 /> I 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 /> If the facility has more components than this form accommo6afes, additfolniff copies of this page may be attached. <br /> r FRR a [rA wnln Fm+imwiar+lal RprwHnn Svcfwn to = kiPn ifirwAm I U%T = I Indpwww en l ctivarw tank i(`r =1ntPnv4innal r`.rv1P (`.n; ;nr l <br />