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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 ❑X 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 195304 <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 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): EBW 71X Spill Bucket install <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 4 <br /> TANK ID: (By tank number,stored product,etc.) T-1 10,000 G Soap <br /> Spill Container Manufacturer: EBW <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 V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container:(Inches) 13 <br /> Depth of Spill Container:(Inches) 221/2 <br /> Does the spill container have a 5 gallon capacity? El 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: Z Pass ❑ Fail ❑ Pass El Fail ElPass ElFail ❑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 /> First test was visibly losing water,test aborted and cause of leak investigated.Found fill adapter cracked.Replaced fill adapter,retested to pass. <br /> See data page attached for additional information. <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=Intemational Code Council <br /> UN-108 www.unidocs.org 1/1 -Rev.06/14/18 <br />