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UNDERGROUND STORAGE TANK <br />an i <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Test ❑ Repair Test Z 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID Date of Spill Container Test <br />10180943 2/25/2020 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />SHOP N GO #3 <br />Business Site Address City IP Code <br />4511 PACIFIC AVE STOCKTON, CA 7;95207 <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 />DAVID WINKLER (209) 744-0112 <br />Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />08-1739 Ex.3/31 /20 8883059 -UT <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tite #10009853708 Ex. 11/29/20 <br />OPW #104-633 Ex. 3/14/2020 MAY 18 <br />111. SPILL CONTAINER TESTING INFORMATION <br />FNVIRONMENITAI <br />Test Method Used: ® Manufacturer Guidelines (Specify): WATER TEST HEALTH DEPARTMENT <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the testing procedures and all documentation required to determine the results. <br />Rp <br /># of Attached Pages <br />TANK ID: (By tank number, stored product, etc.) <br />87 <br />91 <br />Spill Container Manufacturer: <br />OPW <br />OPW <br />Method of Cathodic Protection: <br />9 Non -Metallic <br />® Non -Metallic <br />❑ Non -Metallic <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Isolation <br />❑ Isolation <br />❑ Isolation <br />❑ Other (specifyin v.) <br />❑ Other (specify in V.) <br />❑ Other (Specifyin v.) <br />❑ Other (Specify in V.) <br />Inside Diameter of Spill Container: (Inches) <br />11 <br />11 <br />Depth of Spill Container: (Inches) <br />14 <br />14 <br />Does the spill container have a 5 gallon capacity? © Yes ❑ No <br />© Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Method to Keep Spill Container Empty: Valve <br />R Drain Valve <br />❑ Drain Valve <br />❑ Drain Valve <br />LOOnsite Pump❑ <br />Onsite Pump <br />❑ Onsite Pump <br />❑ Onsite Pump <br />(Specify in V.) <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V.) <br />IV. SUMMARY OF <br />TESTING RESULTS <br />Spill Container Test Results: 9 Pass ❑ Fail ® Pass ❑ Fail ❑ Pass 171 Fail ❑ 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 />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 W <br />If the farility has more components than this form <br />orm accommodates, additional copes of this page maybe attached. <br />CERS = California Environmental Reporting System, ID = Identification, UST =Underground Storage Tank, ICC = International Code Council <br />