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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> ype of <br /> TAction F1Installation Test 1771Repair Test [E 12 Month Test <br /> 1 . FACILITY INFORMATION <br /> Date of Spill Container Test <br /> CERS ID 4/23/ 19 <br /> 10180741 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> MANTECA LIQUOR & FOOD <br /> City ZIP Code <br /> Business Site Address 95336 <br /> 890 N . MAIN ST MANTECA , CA <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Phone # <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) (209 ) 744-0112 <br /> EDWARD STEARNS <br /> ICC Certification Expiration Date <br /> Contractor I Tank Tester License # ICC Certification # 11 /9/2020 <br />' 14. 1760 Ex . 9/30/20 888308MT <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 /> I11 . 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 Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> TANK ID : (By tank number, stored product, etc.) 87 91 DIESEL <br /> Spill Container Manufacturer: <br /> OPW OPW OPW <br /> Method of Cathodic Protection: Z Non-Metallic El Non-Metallic 0 Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specifyin V.) <br /> Inside Diameter of Spill Container: (Inches) <br /> 11 11 11 <br /> Depth of Spill Container: (Inches) 13 13 13 <br /> Does the spill container have a 5 gallon capacity? 0 Yes El No Yes ❑ No (] Yes ❑ No El Yes No <br /> ❑ <br /> Method to Keep Spill Container Empty: Z Drain Valve 0 Drain Valve Z Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : n Pass [:1 Fail Z Pass El Fail lX Pass 171 Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" above must be explained in this section . Any additional commen aabe pfjviddde�e , . <br /> All <br /> ENVIRONMENIAL <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTIN fi < t , TItSG <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 /> 1� 40 <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Cal'ifomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Coundl <br />