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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test Repair Test r 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID �7Date of Spill Container Test: <br /> 10165815 9/23/2020 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> 7- ELEVEN # 17334 MKT 2368 ( W747 ) <br /> Business Site Address City: Zip : <br /> 4501 N . PERSHING AVE . @ ROSEMARIE LN . STOCKTON 95207 <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 /> Jesus Saldivar (800) 800-4633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8361393 6/ 13/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> ICC - CA UST Service Technician 8361393 06/13/2021 Tanknology Certification - Level III Spill Container Testing Certification Exam 115240 <br /> 06/09/2022 <br /> 111. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : Manufacturer Guidelines : (Specify) <br /> Industry Code or Engineering Standard : (Specify) PEI RP 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.) Fill T-1 Fill T-2 <br /> RUL PUL <br /> Spill Container Manufacturer: OPW OPW <br /> r Non- Metallic Non-Metallic Non-Metallic Non-Metallic <br /> Method of Cathodic Protection Isolation r Isolation Isolation r Isolation <br /> r Other r Other r 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) 12 12 <br /> Depth of Spill Container: ( Inches) 16 14 <br /> i <br /> Does the spill container have a 5 gallon capacity? W Yes r No W Yes r No r Yes r No Yes r No <br /> Drain Valve W Drain Valve Drain Valve r Drain Valve <br /> Method to Keep Spill Container Empty Onsite Pump Onsite Pump r Onsite Pump Onsite Pump <br /> r Other r Other r Other r Other <br /> Specify in section V) (Specify in section V) (Specify in section V) (Specify in section V) <br /> 9 <br /> W. SUMMARY OF TESTING RESULTS <br /> t Spill Container Test Results FV Pass r Fail FoPass r Fail ['Pass Fail rPass Fail <br /> V. COMMENTS <br /> All items marked failed above must be explained in this section . Any additional comments may also be provided here, <br /> tested req , with H2O due to not ciettino a good suction and Prem . was tested with vacuum unit, <br /> and passed . . . <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <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 /> If the facility has more components than this form accommodates, additional copies of this page may be attached . <br /> I' <br /> CERS=California Environmental Reporting System, ID=Identification, UST=Underground storage tank, ICC=International Code Council <br />