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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 /> 10146285 9/29/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Costco#658 Tracy <br /> Business Site Address City ZIP Code <br /> 3250 West Grant Line Rd. Tracy 95377 <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 /> Chad White (209) 532 - 7320 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Ca623541/09-1747 8152115 2/13/2022 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> Phil Tite #1015593710, ICC Service Technician #8152115 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ® Manufacturer Guidelines: (Specify) 1 hour Lake Test <br /> ❑ Industry Code or Engineering Standard: (Specify) <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.) 87a Fill 87b Fill 91 Fill Additive Fill <br /> Spill container Manufacturer: Phil Tite Phil Tite Phil Tite OPW <br /> ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection ® Isolation ® Isolation ® Isolation ® Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container: (Inches) 10.75 10.75 10.75 11 <br /> Depth of Spill Container: (Inches) 14 14 14 14 <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 ❑ 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 /> 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 /> agzole <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=California Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council <br />