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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Pagel 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 /> 10146143 5/7/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Costco#1031 Manteca <br /> Business Site Address City ZIP Code <br /> 2440 Daniel St. Manteca 95337 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> Isaac Anderson (209)532- 7320 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> CA 623541/09-1749 8146912 06/12/20 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> Phil-Tite #1022863709 <br /> 111. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ®Manufacturer Guidelines:(Specify) 1 hour Lake Test <br /> ❑Industry Code or Engineering Standard:(Specify) <br /> ❑Engineered Method:(Specify) <br /> Att <br /> Attach the testing procedures and all documentation required to determine the results. #of ached Pages <br /> Tank ID:(By tank number,stored product,etc.) 87A Vapor 87B Vapor 91 Vapor Additive Aux <br /> Spill Container Manufacturer: Phil-Tlte Phil-Tlte Phil-rite 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) 10.75 10.75 10.75 11 <br /> Depth of Spill Container:(Inches) 14 14 14 14 <br /> Does the spill container have a 5 gallon capacity? ®Yes ❑No M 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 ❑ Fail 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 /> 1 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 thad4his 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 />