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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 ❑ 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181485 2-13-2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> YRC#813(Tracy) <br /> Business Site Address City ZIP Code <br /> 1535 E.Pescadero Avenue Tracy 95304 <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 /> Michael Stromecki (800)339-9930 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 804904 8339168 3/19/2020 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> Franklin Fueling Systems VR-101 cert#1006623708 exp 11-29-20,OPW EVR-UST#0175532 EXP 9/12/2020 <br /> I11. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): EBW 71X Spill Bucket install,OPW INSTALL AND MAINTENANCE MANUAL <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 9 <br /> TANK ID:(By tank number,stored product,etc.) T-6 Waste Oil tank Field <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection: ❑ Non-Metallic ❑Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑x 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) 12 <br /> Depth of Spill Container:(Inches) 15 <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 ❑ Fail ❑ Pass ❑ Fail 11 ❑ Pass ❑ Faiilj ❑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 /> OPW manufacturer's published test procedure and pass/fail criteria followed.See attached documentation for specifics. <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.06/14/18 <br />