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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM ( Pagel of 1 ) 2ElZU <br /> Type of Action ❑ Installation Test ❑ Repair Test ❑x 12 Month Test <br /> I . FACILITY INFORMATION FWONM1EllLo' EAL HEAITH <br /> CERS ID Date of SpiII�Coptpi�e�rT.eSt� �T <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Lt1U <br /> Stockton Teichert Mobile Equipment <br /> Business Site Address City ZIP Code <br /> 120 Frank Circle Stockton 95206 <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 /> ( 916 ) 372 - 1885 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 617238 �7 8167865 5/ 14/2022 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW , PhikTite <br /> Ill . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify) : <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 <br /> TANK ID : (By tank number, storedproduct, etc.) 1 - Diesel 2-87 3-Waste Oil <br /> Spill Container Manufacturer: <br /> Method of Cathodic Protection: ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑x Isolation ❑x Isolation Z Isolation ❑ Isolation <br /> ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V) ❑ Other (Specifyin V.) <br /> Inside Diameter of Spill Container: (Inches) 13 13 13 <br /> Depth of Spill Container: (Inches) 14 . 5 14 15 <br /> Does the spill container have a 5 gallon capacity? R Yes ❑ No ❑x Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑x Onsite Pump 0 Onsite Pump 0 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 ❑x Pass ❑ Fail ❑x 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 /> Replaced the fill cap on the waste oil tank before achieving a passing result . <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 1 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 = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />