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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 />Business Name (Same as Facility Name or DBA-Doing Business As) <br />Business Site Address City ZIP Code <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 />Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: Manufacturer Guidelines (Specify): <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.) <br />Spill Container Manufacturer: <br />Method of Cathodic Protection: Non-Metallic Non-Metallic 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) <br />Depth of Spill Container: (Inches) <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 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 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 = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />Check If Action Item(s) Are Present <br />PGE095 <br />10148345 09/20/2019 <br />Pacific Gas and Electric Company <br />4040 West Ln.Stockton 95204 <br />Jarrett Flewellyn (714) 560-8222 <br />588098 8028164 2/20/2021 <br />OPW - 0174949 - 07/11/2020 <br />Hydrostatic <br />PEI RP1200 <br />UNLEADED DIESEL WASTE OIL <br />OPW OPW OPW <br />11.00"11.00"11.00" <br />13.5"12.5"13.5" <br />All test water was left on site in a drum.