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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM(Page 1 of 1) <br /> Type of Action ®Installation Test ®Repair Test ❑12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181511 11/07/19 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Kwik Sery BW 98 <br /> Business Site Address City ZIP Code <br /> 2501 Jackson Ave. Escalon 95820 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> Euseblo Sousa (707)545-5522 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Able Maintenance, Inc.-312844 5254516-UT 7/12/21 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> FFS EBW/Phil-Tite EVR Phase 1 Cert# 1012573708 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines(Specify): <br /> m Industry Code or Engineering Standard(Specify): PEI 1200 <br /> ❑Engineered Method(Specify): <br /> Attach the Testing procedures and all documentation required to determine the results. #of Attached Pages <br /> TANK ID:(By tank number,stored product, etc.) 1 91 2 3 4 <br /> Spill Container Manufacturer: Phil-Tite <br /> Method of Cathodic Protection: ®Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> ❑Isolation ❑Isolation ❑ 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" <br /> Depth of Spill Container:(Inches) 14" <br /> Does the spill container have a 5 gallon capacity? ©Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ®Drain Valve ❑Drain Valve ❑Drain Valve ❑Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑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: 0 Pass ❑Fail I Q Pass ❑Fail ❑Pass ❑Fail ❑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 /> Installed new 5 gallon 91 Fill bucket. <br /> Inspector Paul Nso on site. <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, <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=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br />