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CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council <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 />I. FACILITY INFORMATION <br />CERS ID <br />10182103 <br />Date of Spill Container Test <br />12-4-19 <br />Business Name (Same as Facility Name or DBA-Doing Business As.) <br />United Pacific #5446 <br />Business Site Address <br />1403 Country Club <br />City <br />Stockton <br />ZIP Code <br />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.) <br />Garrett Warren <br />Phone # <br />(916) 991 - 1100 <br />Contractor/Tank Tester License # <br />CSLB#803616 <br />ICC Certification # <br />8185019 <br />ICC Certification Expiration Date <br />10/02/19 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />OPW 101018 exp 6-5-21 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method <br />Used: Manufacturer Guidelines: <br />(Specify) <br /> Industry Code or Engineering Standard: <br />(Specify) PEI / RP-1200 <br /> Engineered Method: <br />(Specify) <br />Attach the testing procedures and all documentation required to determine the results. <br /># of Attached Pages <br />3 <br />Tank ID: (By tank number, stored product, etc.) 87 Waste Oil <br />Spill Container Manufacturer: OPW OPW <br />Method of Cathodic Protection <br /> Non-Metallic Non-Metallic Non-Metallic Non-Metallic <br /> Isolation Isolation Isolation Isolation <br /> Other <br />(Specify in section V.) <br /> Other <br />(Specify in section V.) <br /> Other <br />(Specify in section V.) <br /> Other <br />(Specify in section V.) <br />Inside Diameter of Spill Container: (Inches) 12” 12” <br />Depth of Spill Container: (Inches) 13.50” 14.00” <br />Does the spill container have a 5 gallon <br />capacity? Yes No Yes No Yes No Yes No <br />Method to Keep Spill Container Empty <br /> Drain Valve Drain Valve Drain Valve Drain Valve <br /> Onsite Pump Onsite Pump Onsite Pump Onsite Pump <br /> Other <br />(Specify in section V.) <br /> Other <br />(Specify in section V.) <br /> Other <br />(Specify in section V.) <br /> Other <br />(Specify in section V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results Pass Fail Pass Fail Pass Fail Pass Fail <br />V. COMMENTS <br />All items marked “Fail” above must be explained in this section. Any additional comments may also be provided here. <br /> <br /> <br /> <br /> <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, chapter 16, section <br />2637.1 and all the information contained herein is accurate. <br />UST Service Technician Signature: <br /> Garrett Warren <br />If the facility has more components than this form accommodates, additional copies of this page may be attached.