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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 /> 7-20-20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Safeway fuel station <br /> Business Site Address City ZIP Code <br /> 2808 Country club blvd Stockton 95204 <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 /> Adam Taylor (559) 553 - 5420 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1028900 8143455 12-29-20 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑ Manufacturer Guidelines: (Specify) <br /> ® Industry Code or Engineering Standard: (Specify) PEI PR 1200-17 <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,stored product, etc.) 87 91 Diesel <br /> Spill Container Manufacturer: OPW OPW OPW <br /> ® Non-Metallic ® Non-Metallic ® Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container: (Inches) 12 12 12 <br /> Depth of Spill Container: (Inches) 15 15 15 <br /> Does the spill container have a 5 gallon capacity? ®Yes ❑ No ®Yes ❑ No ®Yes ❑ No ❑Yes ❑ No <br /> ® Drain Valve ® Drain Valve ® Drain Valve ❑ Drain Valve <br /> Method to Keep Spill Container Empty ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ® Pass I ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> All 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,chapter 16,section <br /> 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 />