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UNDERGROUND STORAGE TANK <br /> SPILL. CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> E i - -- <br /> Type of Action ❑ installation Test ® Repair Test ❑ 12 Month Test <br /> 10 FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10642219 02/18/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> San Joaquin Regional Transit District <br /> Business Site Address City ZIP Code <br /> 2849 E Myrtle Stockton 95205 <br /> F . lit UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Nicholas Graham-Lewin (209 ) 367 - 4800 Ext, <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 774802 8897286 5/21 /2020 <br /> Spill Container Testing Training and Certifications (List applicable certfflcations.) <br /> OPvv <br /> Ill. SPILL CONTAINER TESTING INFORMATION . <br /> Test Method Used: ` r-. ITiq <br /> - <br /> ❑ Manufacturer Guidelines: (Specify) <br /> i <br /> ® Industry Code or Engineering Standard: (Specify) Hydrostatic E N VI � � .' i� l iVi �. . ° i . , �: � � � 13 <br /> i k k d � _ yA •'�` <br /> ❑ Engineered Method: (Specify) " <br /> i # of Attached Pages <br /> i Attach the testing procedures and off documentation required to determine the results. <br /> .ank ID: (By tank number, stored product, etc.) T3 , 10k, 87/Gas <br /> Spill Container Manufacturer: OPW 4Ji <br /> i 0 Non Metallic ElNon•Metallic El Non Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection ❑ Isolation ❑ Isolation 0 isolation ❑ Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section K) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container: (Inches) 123/4 <br /> Depth of Spill Container: (Inches) 16112 <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No ❑ Yes ❑ 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 ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ Fall <br /> V. COMMENTS <br /> All 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, chapter 16, section <br /> 21137.1 and all the Information contained herein is accurate. <br /> UST Service Technician Signature <br /> Z&OOO�e <br /> ti <br /> ff the facility has more components than this form accommodates, additional coples of this page may be attechad. <br /> CERS a Cardomla Environmental Reporting System, ID = identification, UST = Underground storage lank, ICC = In*natlonal Code Council <br />