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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type o;Action E Installation Test ❑Repair Test E 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181249 11/27/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> ARP MINI MART CORP <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 /> ContractorlTank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1005444 5250451 04/05/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> FFS EVR Phase I Systems# 1031393709 Expires: 03/04/2020 OPW# 0163755 Expires: 06/07/2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑Manufacturer Guidelines:(Specify) <br /> E 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. <br /> Tank ID:(By tank number,stored product,etc.) T2: 87 Master T4: 91 <br /> Spill Container Manufacturer: Phil-rite Phil-rite <br /> ❑Non-Metallic ❑Non-Metallic ❑ Non-Metallic ❑Non-Metallic <br /> Method of Cathodic Protection E Isolation E 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 /> Inside Diameter of Spill Container.(Inches) 11 1/4" 11 1/4" <br /> Depth of Spill Container.(Inches) 15 3/4" 15 7/8" <br /> Does the spill container have a 5 gallon capacity? E Yes ❑No E Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> M Drain Valve E Drain Valve ❑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 in section V.) (Specify in section V.) (Specify in section V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results E Pass ❑ Fail E Pass ❑ Fail ❑Pass ❑Fail ❑Pass ❑ Fail <br /> V. COMMENTS <br /> All items marked"Fail'above must be explained in this section.Any additional comments may also be provided here. <br /> n � . <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. !_,v V i i <br /> UST Service Technician Signature p DEPARTMENT <br /> If the facility has more components than this form accommfJdates,additional copies of this page may be attached. <br /> r.FRC o raMrvnG Fnvinvntwntal Rarvwtim Cvcfarn In a Wrxn fim� 1 LCT o 1 Irvlaenrrw mrl 4rwww rank Irr:o 1ntarnatkv of Cnrin r w mril <br />