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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM ( Page 1 of 1 ) <br /> Type of Action ❑ Installation Test ❑ Repair Test (] 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181545 3/8 /2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> BAGLEY - SAN JOAQUIN COUNTY CORP YARD <br /> Business Site Address City ZIP Code <br /> 1810 E . HAZELTON AVENUE STOCKTON , CA 95205 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> e # <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phon <br /> ZANE NIMMO (209 ) 744-0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 04- 1676 Ex . 3/31 / 19 8883064- UT 6/ 1 /2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 10009843708 Ex. 11 /29/2020 ' <br /> NEE <br /> OPW # 104-632 Ex. 3/ 14/2020 <br /> 111 . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify): O P W PHASE I LAKE TEST <br /> N industry Code or Engineering Standard (Specify) : ENVIRONMENTAL HEALTH <br /> ❑ Engineered Method (Specify) : D F <br /> NT <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.) 1 - 87 OCT 2 - DSL #2 <br /> Spill Container Manufacturer: O P W O P W <br /> Method of Cathodic Protection: Nx Non-Metallic Zx Non-Metallic ❑x Non-Metallic N Non-Metallic <br /> N Isolation Z Isolation ❑ Isolation ❑ Isolation <br /> N Other (Specify in V) N Other (Specify in V.) N Other (Specify in V.) El Other (Specify in v.) <br /> Inside Diameter of Spill Container: (Inches) 11 11 <br /> Depth of Spill Container: (Inches) 13 1 /2 17 1 /2 <br /> Does the spill container have a 5 gallon capacity? El Yes El No 0 Yes N No N Yes ElNo ElYes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve x Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump N Onsite Pump ❑ Onsite Pump N Onsite Pump <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V) ❑ Other (Specifyin V.) j ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ❑x Pass Elail ❑ Pass ❑Q Fail ❑ Pass ❑ 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 /> DIESEL SPILL BUCKET BREACHED INTO UNMONITORED FILL SUMP <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 <br /> !f 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 />