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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 /> 10181249 2/21 /2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> ARP Mini Mart Mobil <br /> Business Site Address City ZIP Code <br /> 25775 S . Patterson Pass Rd . Tracy 95376 <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 /> 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 (List applicable certifications.) <br /> FFS EVR Phase I Systems # 1031393709 Expires : 3/4/2020 OPW # 0163755 Expires: 6/18/2019 <br /> III, SPiLL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑ Manufacturer Guidelines: (Specify) <br /> ® Industry Code or Engineering Standard: (Specify) PEI/RP1200- 17 <br /> ❑ Engineered Method: (Specify) <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. 3 <br /> Tank ID: (By tank number, stored product, etc.) , T1 : 87 Slave T2: 87 Master T3: Diesel T4: 91 <br /> Spilt container Manufacturer: Phil-Tite Phil-Tite Phil-Tite Phil-Tite <br /> ❑ NonWatallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection <br /> ® Isolation ® Isolation 10 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 /> E Inside Diameter of Spill Container: (inches) 11 11 " 11 " F31 <br /> Depth of Spill Container. (inches) 17121 /4161 /8Does the spill container have a 5 gallon capacity? ® Yes ❑ No ❑ Yes ® No ® Yes ❑ No ® No <br /> E <br /> ® Drain Valve ® Drain Valve ® Drain Valve ® Drain Valve <br /> Method to Keep Spill Container Empty <br /> ElOnsite •Pump [I Onsite Pump El Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Speciy in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> N. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results 175 Pass ❑ Fail ❑ Pass ® Fail ® Pass ❑ Fail ❑ Pass ® Fail <br /> V. COMMENTS <br /> Ali items marked Fail" above must be explained in this section. Any additional comments may also be provided here. <br /> All spill buckets passed the hydrostatic test for 1 hour but, the spill buckets on T2 : 87 Master and T4: 91 <br /> do not hold the 5 gallons capacity. The spill buckets need to be replaced and the 4" riser needs to be <br /> cut/threaded or replaced in order to obtain the 5 gallons capacity. <br /> Vol. 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 /> i l`.KRR o r`.alifr►rnla Frnilnvuno+Ha1 Rarx�Mirxr Cvclarn 1f1 = Ir�ti9rafinn I1RT a 1 Irxiomrro tnti atnranatank IrX: � infomatlnnal f`.rvta (`ni �nril <br /> i <br />