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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 /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181511 l 07/29/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> KwikSery #98 <br /> Business Site Address City ZIP Code <br /> 2501 Jackson Ave . Escalon 95320 <br /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Brian McPheely (408) 971 -2445 <br /> Contractor 1 Tank Tester License # ICC Certification # _ ICC Certification Expiration Date <br /> 4851848822062 - _-- -- 11 /9/19 <br /> Spill Container Testing Training and Certifications (List applicable certifications) <br /> 1014303708 / 104773 <br /> Ills SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : la Manufacturer Guidelines (Specify): OPW <br /> ® Industry Code or Engineering Standard (Specify) : PEI 1200 <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 ) 1 Regular 2 Prem 3 Diesel 4 <br /> _ <br /> Spill Container Manufacturer: JEBW Philtite OPW <br /> Method of Cathodic Protection : <br /> (a Non-Metallic ® Non-Metallic ® Non-Metallic ❑ Non-Metallic <br /> I ❑ 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) 13 12 12 <br /> Depth of Spill Container: (Inches) 15 15 11 <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: Q1 Pass ❑ Fail m Pass El Fall ® Pass ❑ Fail El Pass El Fail t <br /> — <br /> _ <br /> �� <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 /> 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 />