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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action 06 Months ❑Installation Test ❑Repair Test ❑ 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10146285 11/15/18 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Costco #0658 <br /> Business Site Address City ZIP Code <br /> 3250 W Grant Line Rd Tracy 95304 <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 /> Nick Harvey (714) 826 - 0352 Ext. <br /> Contractor/Tank Tester License It ICC Certification# ICC Certification Expiration Date <br /> 300345 A B C61/D40 HAZ 5115738 02/13/2019 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑Manufacturer Guidelines:(Specify) <br /> N Industry Code or Engineering Standard:(Specify) PEI RP1200 <br /> ❑Engineered Method:(Specify) <br /> Atta <br /> Attach the testing procedures and all documentation required to determine the results. #of ched Pages <br /> Tank ID:(By tank number,stored product,etc.) 87 T1 Vapor 87 T2 Fill 87 T2 Vapor <br /> Spill Container Manufacturer: Philtite Philtite Philtite <br /> N Non-Metallic N Non-Metallic N Non-Metallic ❑Non-Metallic <br /> Method of Cathodic Protection ❑ Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other ❑Other ❑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" 12e 12" <br /> Depth of Spill Container:(Inches) 11„ 11„ ill. <br /> Does the spill container have a 5 gallon capacity? N Yes ❑No N Yes ❑No N Yes ❑No ❑Yes ❑No <br /> N Drain Valve N Drain Valve N Drain Valve ❑Drain Valve <br /> Method to Keep Spill Container Empty [I Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other ❑Other E]Other El 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 N Pass ❑Fail 1 N Pass N Fail ❑Pass ❑Fail I ❑Pass ❑Fail <br /> V. COMMENTS <br /> All Items marred"Fair 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,chapter 16,section <br /> 2637.1 and all the information contained herein is accurate. 1� <br /> UST Service Technician Signature 1`"rv,'Z <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=Intemational Code Council <br />