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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 0 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181465 4/26/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> RUPI - WATERLOO FOOD MART <br /> Business Site Address City ZIP Code <br /> 4315 E . WATERLOO RD STOCKTON , CA 95215 <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 /> EDWARD STEARNS (209 ) 744 - 0112 <br /> Contractor / 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 /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify): LAKE TEST <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify) : <br /> # of <br /> Attach the testing procedures and all documentation required to determine the results. Attached Pages <br /> TANK ID : (By tank number, storedproduct, etc.) 87 91 DIESEL <br /> Spill Container Manufacturer: OPW OPW <br /> Method of Cathodic Protection : Non-Metallic ❑x Non-Metallic 0 Non-Metallic ❑ Non-Metallic <br /> i <br /> ❑ Isolation El isolation El Isolation 1771 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) 11 11 11 <br /> f <br /> Depth of Spill Container: (Inches) 19 20 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: Drain Valve Z Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump El 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 : Pass ❑ Fail 9 Pass ❑ Fail El Pass ❑ Fail ❑ 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 /> r <br /> R E <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN_ CONDUCTING THIS TESTING <br /> 1 hereby certify that the spill containers were tested in accordance with Ca 0 Ulpor, Ael 614-ti „ ) itl w 3 , Division 3, <br /> Chapter 16, Section 2637. 1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> �( lKq <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 /> i <br />