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Aug , 30 . 2019 MOM Doniee Pump Co No . 2568 P , 7 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM ( Pagel of 1) <br /> Type of Action ❑ Installation Test ❑ Repair Test 19 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Data of spill Container Test <br /> Business Name (Sarno as Facility Name or DBAwDoing Business As.) <br /> Business Site Address City ZIP Code <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown an the ICC Cert cation) Phone # <br /> Mario Romero (209) 537 - 9396 Ext, 80343 <br /> ContrectortTank Tester License # ICC Cerliflcation # ICG certification Expiration Expiration Date <br /> 80$4353 10/13/19 <br /> Spill Container Testing Training and Certifications (List appiloeble ceitit(cations.) <br /> OPw #100213 <br /> til. SPILL CONTAINER TESTING INFORMATION <br /> Teat Method Used: <br /> (Manufacturer Guidelines: (Specify) <br /> Ej Industry Code or Engineering Standard: (Specify) <br /> ❑ Engineered Method: (Specify) <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> Tank ID. (By tank number, stored product, etc.) <br /> Spill Container Manufacturer: W 0 <br /> fA Non-Metallic Non4etallic ❑ Non•Metalgc ❑ Nan Meteilic <br /> L1Isolation Isolation ElIsolation ❑ Isolation <br /> Method of Cathodic Proletilon <br /> ❑ Glitter d Other ❑ Other ❑ Other <br /> (specify in section V.) (Speei(yIn section V.) (Specify in seclian V.) (Specify 11) section V.) <br /> Inside Diameter of Spill Container: (inches) <br /> i tt <br /> Depth of Spill Container: (inches) <br /> I <br /> Does the spill container have a 5 gallon capaoily? Q1 Yes 0 No Yes Q No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Drain Valve Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite pump <br /> ❑ Other ❑ tither ❑ Other ❑ Other <br /> (Speciryin section V,) (Specify in secllon V.) (SpecW in section V.) (Specify In section V.1 <br /> IV , SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results Pass ❑ Fail Pass ❑ Fall ❑ Pass ❑ Faii ❑ Pase ❑ Fail <br /> V, COMMENTS <br /> Ali items marked rsil° above must be explained in this section. Any additional oomments may also be provided here, <br /> VI . CERTIFICATION 13'Y UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the spill container$ were tested in accordance with California Code of Regulations , titie 23, division 3, chapter 16, section <br /> 2637.1 and all the informaon contained herei <br /> tin Is accurate . <br /> *13Ci1&1tyhasm <br /> e Technician attire <br /> 02 eiw <br /> a components than this forth accommodates, additional copies of this page maybe attached. <br /> . „n _ ,•. _, _ _:_ r... .. ..,,,,,..�..f o....n.at..N Q.,etn.+, in = L1oNHHraHnn I LS T = i indAmm nd gtnraop tank ICC !, Intemationai Code Council <br />