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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page f of 1) <br /> IF, n ❑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) Lf 3 <br /> S t-i ,(—r !Y+Z) <br /> Business Sh Address __TCity ZIP Code <br /> , N -0 1Mtc�W "�con't I q 5331 <br /> li. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification) Phone# <br /> &.1 LetY.a r• 559 '- ',Iqq -t 7-70 <br /> Contractor 1 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 /> B Industry Code or Engineering Standard(Specify): t , k Y <br /> IL <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: [3'Non-Metalfic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> ❑Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(Specify in V.) ❑Other(Specffyin 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? 7kYes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: (Drain Valve ❑Drain Valve ❑Drain Valve ff 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 I ❑Pass ❑Fail <br /> ❑Pass E]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 /> brope ­V'A6e R44v_,flqa.� <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 Signa ure <br /> If the facili has more ca one 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 />