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UNDERGROUND STORAGE TANK AUG 10 202D <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Test ❑Repair TestQW� j1B -T <br /> I. FACILITY INFORMATION )F=0AR TN,4F <br /> CERS ID DNT <br /> ate of Spill Container Test <br /> 10154767 07-29-2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Lawrence Livermore National Laboratory Bldg. 882 <br /> Business Site Address CftyZIP 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(Pont 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): CPW IUM Man_u_aT__ <br /> ®Industry Code or Engineering Standard(Specify): PEI 1200 <br /> ®Engineered Method(Specify): U.1 gp 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.) Diesel <br /> Spill Container Manufacturer: UHVV <br /> Method of Cathodic Protection: ®Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> 9 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.) ❑Other(specify in V.) ❑Other(Specify in V) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ®pass ❑Fail 1 ❑Pass ❑Fail I ❑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 from 9:28a @14.50"to 9:49a @ 14.49"= -0.01 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.06/14118 <br />