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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 ® 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10156809 01 /22/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Safeway <br /> Business Site Address City ZIP Code <br /> 2802 Country Club Blvd 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 /> Brian McPheely (916) 649-8670 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8822062 11 /9/19 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 1014303708 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> 0 Industry Code or Engineering Standard (Specify): PEI 1200 <br /> ❑ Engineered Method (Specify) : <br /> # <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.) 1 Regular 2 Prem 3 Diesel 4 <br /> Spill Container Manufacturer: CNI CNI CNI <br /> Method of Cathodic Protection : ® Non-Metallic ® NonWetallic ® Non-Metallic ❑ Non =Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify In V.) ❑ Other (Specify in V) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 13" 13" 13" <br /> Depth of Spill Container: (inches) 16" 16" 16" <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No © Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty : ® Drain Valve ® Drain Valve ® Drain Valve ❑ Drain Valve <br /> ® Onsite Pump ® Onsite Pump VI 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 : ® Pass ❑ Fail VI Pass ❑ 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 /> 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 <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Califomia Environmental Reporting System, ID = Identification , UST = Underground Storage Tank, ICC = International Code Council <br />