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UNDERGROUND STORAGE TANK <br /> SPiLL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> TypeAt ❑ Installation Test ® Repair Test ❑ 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10182105 12/19/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> San Joaquin County Facilities Management (Jail) <br /> Business Site Address City ZIP Code <br /> 7000 Michael Canlis French Camp 95231 <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 /> Andy Bagley (209) 367 - 4800 Ext, <br /> Contractorfrank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 774802 8012449 12/24/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> 2) Manufacturer Guidelines: (Specify) Water Test <br /> ❑ Industry Code or Engineering Standard: (Specify) <br /> ❑ Engineered Method: (Specify) <br /> Attach the testing procedures and all documentation required to defwmine the results. # of Attached Pages <br /> Tank ID: (By tank number, stored product, etc.) S-DSL <br /> Spill Container Manufacturer: EBW <br /> 0 Non-Metallic ❑ Non•Metallic ❑ Non-Metallic ❑ NonWetallic <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) 14 <br /> Depth of Spill Container: (Inches) 12 <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 ❑ Onshe Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Speclly In section V) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> N. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ® Pass ❑ Fait ❑ Pass ❑ Fail ❑ Pass 0 Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> All items marked Fail" above most be explained in this section. Any additional comments may also be provided hens. <br /> Replaced drain valve PN 70533601 like for like, re-tested -� � �, FY 5 -r <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the spill contalners were tested In accordance with California Code of Regulations, title 23ad' ' " <br /> 2637.1 and all the information contained herein Is accurate. ._ ? f Q sus Yo 1\ L l_ <br /> UST Service Technician lgripture tt1 F i\ <br /> if the facll as moof corn vents than this nn accommodates, additional copies of this page may be attached. <br /> CERS = Catifomia Environmental Reporting System, ID = tdar0cation, UST = Underground storage tank, ICC = 1nEema6onal Code Council <br />