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UG010 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Test ❑ Repair Test Q 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181541 01/08/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Pacific Bell Telephone Co. dba AT&T California <br /> Business Site Address jEscalon <br /> ity ZIP Code <br /> 1812 Coley Ave. 95320 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Narne of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> Craig Feezell (209)643-9747 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 588098 8374133 7/3/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> Franklin Fueling 1014413708 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑ Manufacturer Guidelines(Specify): <br /> Hydrostatic <br /> 0 Industry Code or Engineering Standard (Specify): PEI RP 1200 <br /> ❑ Engineered Method (Specify): <br /> #of <br /> Attach the testing procedures and all documentation required to determine the results. Attached Pages <br /> TANK ID: (By tank number, stored product,etc.) UG01 00001 <br /> Spill Container Manufacturer: Phil Tite <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in VJ ❑Other(Specify in V) <br /> Inside Diameter of Spill Container: (Inches) 11.00" <br /> Depth of Spill Container: (Inches) 14.25" <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: ❑x Drain Valve ❑ Drain Valve ❑ 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: ❑x Pass ❑ Fa,17T ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items(narked"Fail"above must be explained in this section. Any additional comments may also be provided here. <br /> —heck If Action Item(s)Are Present <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 <br /> Signature <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 Council <br />