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19032O-597 <br />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 />If the facility has more components than this form accommodates, additional copies of this page maybe <br />I. FACILITY INFORMATION <br />CERS ID <br />10181481 <br />Date of Spill Container Test <br />04/03/19 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Manteca CA FO REGEN <br />Business Site Address <br />2551 E. Louise Ave. <br />City <br />Lathrop <br />ZIP Code <br />95330 <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 />Kraig Kinder (888) 5888737 <br />Contractor / Tank Tester License # <br />703190 <br />ICC Certification # <br />ICC Certification Expiration Date <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling <br />Ili. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />J$( Manufacturer Guidelines (Specify): <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the testing procedures and all documentation required to determine the results. <br /># of Attached Pages <br />TANK ID: (By tank number, stored product, etc.) MANTECA/Diesel <br />Spill Container Manufacturer: OPW <br />Method of Cathodic Protection: Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V) <br />Inside Diameter of Spill Container: (Inches) 12" <br />Depth of Spill Container: (inches) 11" <br />Does the spill container have a 5 gallon capacity? ❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Method to Keep Spill Container Empty: ® Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Drain Valve <br />❑ Onsite Pump <br />I ❑ Other (Specify in V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: $) Pass ❑ Fail ❑ Pass ❑ Faii <br />❑ Pass ❑ Fail <br />❑ 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 />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 Digitally signed by Kraig Kinder <br />Kraig Kinder Date: 2019.04.0309:12:54-07'00' <br />attached. <br />CERS = California Environmental Reporting System, ID =Identification, UST =Underground Storage Tank, ICC = International Code Council <br />