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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 ❑x 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10151123 10/4/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Sprint Stockton <br /> Business Site Address City ZIP Code <br /> 3807 Coronado Ave . 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 /> Benjamin Jauregui ( 760) 743-0518 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 708231 8277373 9/ 12/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications) <br /> OPW <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> ❑x Industry Code or Engineering Standard (Specify): PEI 1200 <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.) UST 10 , 000 <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection: ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> 9 Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) ❑ Other (Specify in V) <br /> Inside Diameter of Spill Container: (Inches) 11 11 <br /> Depth of Spill Container: (Inches) 12 " <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x 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 : Z Pass ❑ Fail ❑ Pass ❑ Fail ❑ 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 /> Double Wall Spill Bucket <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 &Q2 <br /> If the facility has more components than #YisArm 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 />