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UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Test epair Test ❑ 12 Month Test <br />1. FACILITY INFORMATION <br />CERS ID <br />Date of Spill Container Test <br />v ash = <br />s-» -a 3 <br />Business Name(Same Facility Name or DBA -Doing Business As.) <br />5 - W -C <br />Business Site Address <br />_7D'7 <br />City <br />ZIP Code <br />E_,40TH tz <br />rk\ . (_ <br />Sa3 <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 />GREG KAISER I (209) 401 - 2379 Ext. <br />Contractor/Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />859535 <br />5252318 <br />9/20/23 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />S 6�_L)VL- )p 4_2 2 s Sf^ <br />III_ SPILL CONTAIN -R TESTING INFORMATION <br />Test Method Used: rrWanuhacturer Guidelines: (Specify) z { v- 2 -,CA 4-(� TLS{ <br />❑ Industry Code or Engineering Standard: (Specify) <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.) <br />'r1- 171 <br />Spill Container Manufacturer. <br />rj W <br />,Non -Metallic <br />❑ Non -Metallic <br />❑ Non -Metallic <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Isolation <br />❑ Isolation <br />❑ Isolation <br />Method of Cathodic Protection <br />❑ Other <br />❑ Other <br />❑ Other <br />❑ Other <br />(Specify in section V) <br />(Specify in section V) <br />(Specify in section V) <br />(Specity in section V) <br />Inside Diameter of Spill Container: (Inches) <br />i C) <br />ne�th . f c„in rpptofnor nn- e—i <br />Does the spill container have a 5 gallon capacity? <br />'fes [INo <br />❑ Yes [INo <br />[IYes ❑ No <br />❑ Yes ❑ No <br />29:Drain Valve <br />❑ Drain Valve <br />❑ Drain Valve <br />❑ Drain Valve <br />Method to Keep Spill Container Empty <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Other <br />❑ Other <br />❑ Other <br />❑ Other <br />(Specify in section V) <br />(Specify in section V) <br />(Specify in section V) <br />(Specify in section V) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results Pass ❑ Fail <br />11 ❑ Pass ❑Fail <br />❑Pass ❑Fail <br />❑Pass ❑ Fail <br />V. COMMENTS <br />All items marked °Fail" a ve must be explained in this sTchon. Any additional co�/nents ay also a provided <br />re. <br />U <br />113 I r (l <br />I <br />KJZ^t `Q <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br />I hereby certify that the soillyontainers were tested in accordance with California Code of Requisitions. title 23, division 3, chanter 16. section <br />2637.1 and all t infogpoliift contained herein is accurate. <br />UST Service is Signature <br />j <br />C e^ <br />h the f T' more components than this forth acconyWoddites, additional copies of this page may be attached. <br />CE =Ca6farria Enukionnia tal Raportlrg Systam, ID a kkntl6rallon. UST= Undergrotind storage tank ICC = lnWrredor d Cade Council <br />