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UNDERGROUND STORAGE TANK <br />c,tc ,pw„my „d, ,ours cvmponenrs roan rms rorm accommodates, <br />SPILL CONTAINER TESTING REPORT FORM (Page I of 1) <br />Type of Action ❑ Installation Test ❑ Repair Test ❑x 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID Date of Spill Container Test <br />10181267 7� 10/05/2018 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />CALIFORNIA NATIONAL GUARD - STOCKTON AIRPORT <br />Business Site Address <br />ity <br />ZIP Code <br />2000 STINSON j;JOCKTON <br />95206 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) # <br />TPhone <br />Felix Ramirez (209) 744-0112 <br />Contractor /Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />08-1740 5-31-20 <br />8883072 -UT <br />11/22/2018 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tite #1009883708 11-16-18 <br />OPW #104634 3-14-20 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />Manufacturer Guidelines (Specify): OPW <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 /># of Attached Pages <br />TANK ID: (By tank number, stored product, etc.) <br />JET <br />Spill Container Manufacturer: <br />OPW <br />Method of Cathodic Protection: <br />❑x Non -Metallic <br />Non -Metallic <br />❑ 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 />Depth of Spill Container: (Inches) <br />13 <br />Does the spill container have a 5 gallon capacity? <br />[j] Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Method to Keep Spill Container Empty: <br />❑x Drain Valve <br />❑x Drain Valve <br />El 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 (Specify in V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: <br />❑x Pass ❑ Fail ❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ 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 <br />additional copies of this page may be attached. <br />CERS = Califomla Environmental Reporting System, ID =Identification, UST =Underground Storage Tank, ICC = International Code Council <br />