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UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />m t_..tall u..., Test (-T Reoair Test 0 12 Month Test <br />Type of Action u �� �o_��=,•..• -• — <br />1. FACILITY INFORMATION <br />Date of Spill Container Test <br />,ERS ID <br />2/10/20 <br />10180637 <br />Business Name (Same as Fa: i)ity Name or DBA -Doing Business As) <br />GEMCO RIPON TRUCK PLAZA <br />City ZIP Cade <br />Business Site Address RIPON. CA 95366 <br />1022 S. FRONTAGE RD <br />11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <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$#883OBO-UT 11/9/2020 <br />14-1760 Ex. 9/30/20 <br />Spill Container Testing Training and Certifications (List applicable cerrmcadons.) <br />Franklin Fueling - EBW & Phil Tile #1009893708 Ex. 11/29/2020 <br />OPW #104635 Ex. 3/14/2020 <br />111. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />0 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 />—ANK ID: (By tank number• stored product, etc.) <br />87 <br />91 <br />.pill Container Manufacturer: <br />Method of Cathodic Protection: <br />OPW <br />0 Non -Metallic <br />OPW <br />m Non -Metallic <br />0 Non -Metallic <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Isolation <br />❑ Isolation <br />❑ Isolation <br />❑ Other (Specify in v.) <br />❑ Other (specify in V.) <br />❑ Other (specify in V) <br />❑ Other (Specify in V.) <br />Inside Diameter of Spill Container. (inches) <br />11 <br />11 <br />Depth of Spill Container: (inches) <br />131/2 <br />0 Yes ❑ No <br />141/2 <br />l[A Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Does the spill container have a 5 gallon capacity? <br />Method to Keep Spill Container Empty: <br />0 Drain Valve <br />0 Drain Valve <br />❑ Drain Valve <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Onsite Pump![] <br />Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V.) <br />Other (Speciry m V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: 0 Pass ❑ Fail 0 Pass []Fail ❑ Pass ❑ Fail I ❑ 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 />BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br />VI. CERTIFICATION <br />... .-...e__..i...:. _ Yit a 94 nivfeinn 3. <br />I hereby certify that the spill containers were tested in accordance wirn Cau,vriva <br />"hapter 16, Section 2637.1 and all the information contained herein is accurate. <br />more components <br />of this page may oe <br />CERS= California Environmental RepaNS System, ID = Idereiiiraton. UST = Underground Storage Tank, ICC = international Code Council <br />