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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 ❑x 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10456027 5/20/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> TRACY 76 <br /> Business Site Address City ZIP Code <br /> 2420 W. GRANTLINE RD ITRACY, CA 95376 <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 /> EDWARD STEARNS (209) 744-0112 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 14-1760 Ex. 9/30/20 8883080-UT 11/9/2020 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) ,n.. i9 <br /> RF °" 'i' !., <br /> E D_ <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): LAKE TEST PJIN <br /> ❑Industry Code or Engineering Standard(Specify): ENVIRONMENTAL HEALTH <br /> ❑Engineered Method(Specify): nFPARTM _ <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.) 87 91 DIESEL <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic ❑x Non-Metallic ❑Non-Metallic <br /> ❑ Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container:(Inches) 11 11 11 <br /> Depth of Spill Container:(Inches) 14 14 14 <br /> Does the spill container have a 5 gallon capacity? R Yes ❑No [j]Yes ❑No EI Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve x❑Drain Valve ❑x Drain Valve ❑Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in V.) ❑Other(Specify in V) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: 11 ❑x Pass ❑Fail Z Pass ❑Fail ❑x Pass ❑ Fail 11 ❑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 /> 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 e, <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Califomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=Intemational Code Council <br />