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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM <br /> Type of Action ❑ Installation Test ❑ Repair Test no 12 Month Test <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180975 3-25-2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Stockton 76 <br /> Business Site Address City ZIP Code <br /> 8606 Thornton Rd . Stockton 95209 <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 /> Garrett Warren ( 916 ) 991 - 1100 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CSLB#803616 SWRB#06 -1672 18185019 10-2-2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW EVR 101018 exp . & 9 -2019 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method <br /> Used : ❑ Manufacturer Guidelines : <br /> (Specify) <br /> ® Industry Code or Engineering Standard : RP 1200 <br /> (Specify) <br /> ❑ Engineered Method : <br /> (Specify) <br /> # of Attached Pages <br /> E Attach the testing procedures and all documentation required to determine the results. <br />! Tank ID : (By tank number, stored product, etc.) 87 89 91 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> E <br /> My Non-Metallic (] Non-Metallic (] Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection X Isolation INIsolation X 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) <br /> Depth of Spill Container: (Inches) 10 . 50" 12 . 00" 10 . 50" <br /> Does the spill container have a 5 gallon ❑ Yes I] No I] Yes ❑ No ❑ Yes n No ❑ Yes El <br /> capacity? <br /> X Drain Valve o Drain Valve Q Drain Valve ❑ Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump El 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 X Fail ❑ Pass IN 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 /> The 87 and 91 spill bucket did not hold 5 gallons . The 89 spill bucket failed and was leaking . The threads on the nipple are damaged . <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 /> UST Service Technician Signature <br /> if the facility has more components than t is rm accommodates, additional copies of this page maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council <br />