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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 /> 10151123 10/4/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Sprint Stockton <br /> Business Site Address City ZIP Code <br /> 2807 Coronado Ave. Stockton 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.) Phone# <br /> Benjamin Jauregui (760) 743-0518 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 708231 8277373 9/12/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑ Manufacturer Guidelines(Specify): <br /> ❑x Industry Code or Engineering Standard (Specify): PEI 1200 <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.) UST 10,000 <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection: ❑ Non-Metallic ❑Non-Metallic ❑ Non-Metallic ❑Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑x Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 1 lit <br /> Depth of Spill Container: (Inches) 12" <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑No ❑Yes ❑ No ❑Yes ❑No ❑Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in V.) ❑Other(Specify in V) ❑Other(Specify in V) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑x Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass El 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 /> Double Wall Spill Bucket <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 &C)� <br /> If the facility has more components than Xisl6rm accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br />