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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 /> 3/6/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> California Stop <br /> Business Site Address City ZIP Code <br /> 2224 S Manthey Rd Stockton , CA 95026 <br /> 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Brian Dunahay (248 ) 978-5420 <br /> Contractor / Tank Tester License # ICC Certin802143 & UT <br /> ICC Certification Expiration Date <br /> 956593 12 / 16/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Caldwell Level Indicator 5/1 /2021 <br /> 111 . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> ❑x Industry Code or Engineering Standard (Specify) : 1 - hr lake test <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.) 87 E91 Diesel <br /> Spill Container Manufacturer: OPW OPW RP <br /> Method of Cathodic Protection : ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic R Non-Metallic <br /> Isolation N Isolation [EIsolation ElIsolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 12 12 12 " <br /> Depth of Spill Container: (Inches) 14 . 5 " 12 . 75 " 11 zY <br /> Does the spill container have a 5 gallon capacity? R Yes ❑ No Fxl Yes ❑ No i] Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve N Drain Valve Z Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump El Onsite Pump El Onsite Pump <br /> El Other (Specify in V.) Other (Specify in V.) R Other (Specify in V.) El Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : Pass ❑ Fail Z Pass ❑ Fail Pass EJ Fail <br /> El 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 /> Diesel 9 . 85' <br /> 91 10" @1000 <br /> 87 12 . 75" @ 1045 <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, <br /> Chapter 16 , Section 2637. 1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> ff 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 />