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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 ❑X 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10726990 8/27/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Pilot 1017 <br /> Business Site Address City ZIP Code <br /> 345 Roth Rd . French Camp 95231 <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 /> Jacob Weaver ( 877) 972 - 7581 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 804431 8338858 - UC 2/ 14/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW# 176489 EXP , 12/10/20202 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> ❑x Industry Code or Engineering Standard (Specify) : HYDROSTATIC <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.) 87 91 <br /> Spill Container Manufacturer: OPW OPW <br /> Method of Cathodic Protection : ❑x Non-Metallic ZNon-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑Other (Specify in V.) ❑Other (Specify in V.) ❑Other (SpecffyinV.) ❑ Other (Specifyin V) <br /> Inside Diameter of Spill Container: (Inches) 12 If 12 �� <br /> Depth of Spill Container: (Inches) 16 It 16 � � <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑x Yes [:] No ❑Yes ❑ No ❑Yes ❑ No <br /> Method to Keep Spill Container Empty: Z Drain Valve 9 Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specifyin V.) ❑ Other (Specifyin V) ❑ Other (Specifyin V.) ❑ Other (Specifyin V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ❑x Pass ❑ Fail NPass ❑ Fail ❑ Pass ❑ Fail ❑ 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 /> 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 <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS =Ca lifomia EnvironmentalR eportingSy stem, ID = Identification,UST =Undergr ound Storage Tank, ICC =1n temational Code Council <br /> i <br />