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Jun, 26. 2020 3:40PM Donlee Pump Co No. 4053 P. 8 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINED{TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ^ ❑Installation Test W Repair Test �❑FMonthI. FACILITY INrOlgMATION <br /> CERS til Date of Spill Cont <br /> Business Name(same es Facility Herne or DBA-Doing Easiness As.) <br /> Business Site Adaress City ZIP Code <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service echnfclan Performing tt,e Tesl(Print 8s shown on file(CC Cerffric9llon:jjE(209) <br /> e# <br /> 5!7 -9396 Ext. <br /> ContractoriTanle Tester License A ICC Certification ft on Expiration gala <br /> Spill Container`Nesting Training and Cisaificallons(List appfi0able certifications.) <br /> Ill. SPILL CONTAINER TESTING INFORMATION <br /> Teal Malhod Used: <br /> Manufacturer Guidelines:(Specify) I-,y y4STP rT-(_ <br /> ❑Industry Code or Engineering Standard:(Speclfy) <br /> ❑Engineered N161hod:(Specify) <br /> #of AtlachedTages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> Tank ID:(fly t8nk number,stored product;ela.) f DTi<S� <br /> Spill Container Manufacturer: OPS C) <br /> }Non Metallic 2rNon-Metallic Non-Metallle ❑Non-Metallic <br /> El ❑Isolailon ❑Isolation [I Isolation <br /> Method of Cathodic Protection <br /> ❑Other ❑Othor ❑Other ❑Other <br /> fSp6dry in sacrion V.) (Specify in section V) r7p!t <br /> (Specify in section V) <br /> Inside Diameter of Spill Container:(Inches) �) f Depth of Spill Conlalnec (inches) i <br /> Does the spill container have a 5 gallon capacity? W'Yes ❑No �(es ❑No Yes ❑t El Yes ❑No <br /> V(Drain Valve q(aln Valve JZDraln Valve ❑Oraln Valve <br /> Method to Keep Spill Container Empty El Onsite Pump ❑Onsite Pump E]Onsite Purrip ❑on Pump <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Spedty In section V.) (Specify in section V) I (Specify in section V.) L(Specifyin section V) <br /> IV, SUM ARY,OF.TESTING RESULTS <br /> Spill Container Test Results Pass El Fall Vass ❑Fail ❑Pass Fafl ❑Pass ❑hail <br /> T <br /> V. COMMENTS <br /> All ltom marked'Poll"above must he explained in this section.Arty arlditional comments may also ba provided here. <br /> psetE� �u4r cwt;��i �t,�cs��,�Tai��' +M'► "vkah ED "-V,1,6 <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,chapter 16,section <br /> 2637.1 and all th Inf_ormallo ntalned herein Is accurate. <br /> UST Se ntcl gnat e <br /> It i e facility hanre components than this form accommodates,additional copies of this page may be attached. <br /> IMT=I lnrtornrnnnrl=fnonA hank.ICC=International Code COUndt <br />