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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 /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181433 05/09/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Unocal255886 <br /> Business Site Address City ZIP Code <br /> 2701 West March Lane Stockton 95219 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Eusebio Sousa (707) 545-5522 <br /> Contractor ! Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Able Maintenance , Inc, - 312844 5254516-UT 7/18/19 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW EVR Phase 1 - UST Cert# 100414 <br /> 111 . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ® Manufacturer Guidelines (Specify) : OPW <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, stored product, etc.) 1 87 2 91 3 4 <br /> Spill Container Manufacturer: OPW OPW <br /> Method of Cathodic Protection: ❑ Non-Metallic ❑ Nan-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> 2 Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specifyin V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 12.0" 12 .0" <br /> Depth of Spill Container: (Inches) 12 . 250 13 .0" <br /> Does the spill container have a 5 gallon capacity? 2 Yes ❑ No 2 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: 2 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: ® Pass ❑ Fail ® Pass El Falill ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" above must be explained in this section. Any additional comments mar, q 7be pravided-here - , <br /> � 4 <br /> Ell <br /> Replaced Bucket with Permits . - Tested & Passed. _ , <br /> 1 ,IN {) a, ( 0 191 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCT T H'JEST"� <br /> 1 hereby certify that the spill containers were tested in accordance with California Code of Regulations, Tf4le 24; bIvision 3 , <br /> Chapter 16, Section 2637.1 and all the information coulpined 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 />