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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 Z 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 2 / 14/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> AG SPANOS JET CENTER <br /> Business Site Address City ZIP Code <br /> 4800 S . AIRPORT WAY STOCKTON , CA 95208 <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 /> EDWARD STEARNS 1 (209) 744- 0112 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 9/30/20 8883080- UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite #1009893708 Ex. 11 /29/2020 <br /> OPW # 104-635 Ex. 3/14/2020 <br /> 111 . SPILL CONTAINER TESTING INFORMION <br /> Test Method Used : 0 Manufacturer Guidelines (Specify) : LAKE TEST <br /> i; <br /> 4 . <br /> ❑ Industry Code or Engineering Standard (Specify): <br /> ❑ Engineered Method (Specify) : f= k 1 0 \" <br /> `:bfAtt &.I . Rages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> TANK ID : (By tank number, storedproduct, etc.) JET- 1 JET-2 JET-3 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection : ❑x Non-Metallic N Non-Metallic 0 Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (specify in V.) ❑ Other (specify in V.) ❑ Other (Specifyin V) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 11 11 11 <br /> Depth of Spill Container: (Inches) 13 3 12 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No R Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: Drain Valve 0 Drain Valve 0 Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) ❑ Other (Specifyin V) ❑ Other (Specify in V) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : IF 0 Pass ElFail ZPass E] Fail 0 Pass ❑ Fail El 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 /> 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 = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council <br />