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i <br /> BEC - <br /> 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 ENVIRONMENTAL - <br /> CERS ID Date of Spill' 'MV <br /> 10154767 �7 2 IT <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Lawrence Livermore National Laboratory Bldg. 879 <br /> Business Site Address City ZIP Code <br /> 15999 West Corral Hollow Road Tracy 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 /> Brian Thornton 209-834-0792 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> CSLB A, C-10, HAZ #724513 5024962-UC 02-27-2022 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> Caldwell Sump Level Change Indicator Exp. 05-11-2023 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ®Manufacturer Guidelines(Specify): UPW 10M Manual <br /> ®Industry Code or Engineering Standard(Specify): PEI 1200 <br /> ®Engineered Method (Specify): 0.1gp Hydrostatic eS Ing <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.) unleaclea Diesel <br /> Spill Container Manufacturer: <br /> Method of Cathodic Protection: ®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 V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container:(Inches) . <br /> Depth of Spill Container:(inches) <br /> Does the spill container have a 5 gallon capacity? ®Yes ❑No ®Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ®Drain Valve ®Drain Valve ❑Drain Valve ❑Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(specify in V.) I ❑Other(Specify in V) I ❑Other(Specify In V.) ❑Other(Specify In V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ®Pass ❑Fail 1 ®Pass ❑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 /> Using Caldwell Sump Level Change Indicator <br /> Unleaded from 10:16a @12.00"to 10:45a @ 11.99"= -0.01 change. Pass <br /> Diesel from 10:58a @ 12.25"to 11:19a @ 12.25"=0.00 change. Pass <br /> SJEHD on site. <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 /> 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 /> UN-108 www.unidocs.org 111 -Rev.06114/18 <br />