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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 /> 10156057 05-20-2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> UPS <br /> Business Site Address City ZIP Code <br /> 1532 North Broadway Stockton 95205 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> David Pereira (510) 889- 0908 Ext. <br /> Contractorlrank Tester License# ICC Certification# ICC Certification Expiration Date <br /> R.L Stevens Co/415807 5240739-UT 08/31/2020 <br /> Spill Container Testing Training and Certifications(List applicable certdications.) <br /> Service Tech / OPW <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑Manufacturer Guidelines: (Specify) <br /> ® Industry Code or Engineering Standard:(Specify) PEI/RP 1200 <br /> ❑ Engineered Method:(Specify) <br /> #of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> Tank ID: (By tank number,stored product, etc.) T-1 Diesel <br /> Spill Container Manufacturer: OPW <br /> M 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) 12" <br /> Depth of Spill Container: (Inches) 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 [I Fail ❑Pass E]Fail ❑ Pass El Fail E] Pass E] Fail <br /> V. COMMENTS <br /> All items marked"Fair above must be explained in this section.Any additional comments may also be provided here. <br /> Liquid tested for 1 hr at 13 1/2" with no loss <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 i rate. <br /> UST Service Technician Signature - <br /> If the facility has more components thanchisform aZ'commodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,LIST=Underground storage tank ICC=International Code Council <br />