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01 <br /> 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 /> 11/08/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Unified Grocers,Inc. <br /> Business Site Address City ZIP Code <br /> 1990 Piccoli Rd. Stockton 195215 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the I est(Print as shown on the ICC Certification.) Phone# <br /> Jarrett Flewellyn (714)560-8222 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 588098 8028164 03-29-2019 <br /> CSpill C4ontajner Testing Training and Certifications(List applicable certifications.) <br /> _ Ill. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: EI Manufacturer Guidelines(Specify): Franklin Fueling iNCON TS-STS <br /> Hydrostatic <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> 4 <br /> TANK ID: (By tank number,stored piuducl.etc;) Diesel Diesel <br /> Spill Container Manufacturer: CNI CNI <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> ❑ Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) LI Other(specify in V.) <br /> Inside Diameter of Spill Container: (Inches) <br /> Depth of Spill Container: (Inches) 13.5" 13.5" <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ❑Drain Valve ❑Drain Valve <br /> ❑Drain Valve El Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> 21 Other(Specify in V.) x❑Other(Specifyin V.) ❑Other(specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑ Pass x❑Fail ❑x Pass []Fail ❑Pass ❑Fall ❑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 /> All test water was left on site. <br /> All test water was removed with a hand pump. <br /> Bucket initially failed.Replaced the drain valve and fill cap,test passed. <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 /> �7" <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=International Code Coundl <br />