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h <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Test ❑Repair Test Z 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10397599 11/21/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> SUTTER TRACY HOSPITAL <br /> Business Site Address City ZIP Code <br /> 1420 N TRACY BLVD ITRACY, CA 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 /> DAVID WINKLER (209) 744-0112 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 Ex.3/31/20 8883059-UT 1/29/2020 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) " <br /> Franklin Fueling - EBW& Phil Tite #10009853708 Ex. 11/5/2018 <br /> OPW#104-633 Ex. 3/14/2020R E x3 <br /> 7 <br /> III. SPILL CONTAINER TESTING INFORMATION 4 2018 <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): Water test <br /> ❑Industry Code or Engineering Standard(Specify): VI ONME `TAL HEALTH <br /> E]Engineered Method(Specify): --^ <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.) RED DSL <br /> Spill Container Manufacturer: OPW <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.) I ❑Other(Specify in V.) ❑Other(Specifyin V) <br /> Inside Diameter of Spill Container:(Inches) 11 <br /> Depth of Spill Container:(Inches) 13 <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: Z 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: E Pass ElFail E] Pass ❑-FWl—]l ❑ Pass ❑Fail El Pass El 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 /> 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 />