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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test Repair Test 12 Month Test <br /> 1. FACILITYINFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10166017 4/30/2019 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> 7-ELEVEN #32190, MKT 2368 <br /> Business Site Address City: Zip: <br /> 4943 S . KINGSLEY ( FRONTAGE RD) HWY 99 @ ARCH AIRPORT RD STOCKTON 95206 <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 6/16/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> ICC - CA UST Service Technician 8361393 06/16/2019 Tanknology Certification - Level III Spill Container Testing Certification Exam 115240 <br /> 07/06/2019 <br /> Ill. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : Manufacturer Guidelines : (Specify) <br /> Industry Code or Engineering Standard : (Specify) PEI RP 1200 <br /> i <br /> Engineered Method : (Specify) <br /> j # 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.) Fill Fill T5 Fill <br /> RULL MUL PULL <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Non-Mettalic Non-Mettalic NonWettalic Non-Mettalic <br /> Method of Cathodic Protection Isolation 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 12 <br /> Depth of Spill Container: ( Inches) 16 17 18 <br /> Does the spill container have a 5 gallon capacity? ry Yes r No W Yes r No W Yes r No r Yes r No <br /> r Drain Valve W Drain Valve ry Drain Valve Drain Valve <br /> Method to Keep Spill Container Empty r Onsite Pump r Onsite Pump r Onsite Pump r Onsite Pump <br /> r Other Other r Other Other <br /> Specify in section V) (Specify in section V) Specify in section V) Specify in section V) <br /> k <br /> N. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results P—Pass r Fail Pass r Fail r PaSS r Fail Pass r 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 /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> 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 /> 6A 0 <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 />