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UNDERGROUNDSTORAGETANK ' <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action r Installation Test F Repair Test 12 Month Test <br /> 1. FACILRY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10166021 3/112019 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> 7-ELEVEN #32262 , MKT 2368 ( N -3940- 1 <br /> Business Site Address City: Zip: <br /> 2360 W GRANTLINE k205 OFF RAMP TRACY 95376 <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 /> Steve Willems (800) 800-4633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8234559 5/22/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW - EVR Phase 1 903806 03/26/2020 <br /> 111. SPILL CONTAINER TESTING' INFORMATION <br /> Test Method Used : F. Manufacturer Guidelines : (Specify) <br /> 4 Industry Code or Engineering Standard : (Specify) PEI RP 1200 <br /> F' 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 T4 RUL Fill T5 MUL Fill T6 PUL <br /> REG UNLEAD MIDGRADE PREMIUM <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Non-Mettalic W Non-Mettalic r Non-Mettalic Non-Mettalic <br /> Method of Cathodic Protection Isolation r Isolation r Isolation Isolation <br /> r Other F Other r Other r 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) 13 . 75 13 . 5 12 <br /> Does the spill container have a 5 gallon capacity? FV Yes r' No Yes r No W Yes F No Yes r No <br /> W' Drain Valve ' Drain Valve FV Drain Valve Drain Valve <br /> Method to Keep Spill Container Empty r Onsite Pump Onsite Pump r Onsite Pump Onsite Pump <br /> F 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 /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results W,'PaSS F� Fail WPaSS F Fail p- PASS F Fail r7Pass FFail <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 1 � <br /> E <br /> I 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 /> 1 <br /> I <br />