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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 /> 10181003 2/7/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> DAMERON HOSPITAL <br /> Business Site Address City ZIP Code <br /> 525 WEST ACACIA STREET STOCKTON , CA 95203 <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 /> FELIX RAMIREZ ( 209 ) 744 - 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 0 & 1740 5 - 31 -20 8883072 - UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 1009883708 11 /29/20 <br /> OPW # 104634 3- 14-20 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> x❑ Industry Code or Engineering Standard (Specify) : LAKE TEST / PEI <br /> ❑ Engineered Method (Specify) : <br /> # <br /> Attach the testing procedures and all documentation required to determine the results. of Attached Pages <br /> TANK ID : (By tank number, storedproduct, etc.) RED DIE <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection : ❑x Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V) ❑ Other (Specifyin V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 11 <br /> Depth of Spill Container: (Inches) 15 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x 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 : FF ixi Pass ❑ Fail E] Pass E] Fail ❑ Pass E] Fail El Pass El 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 /> START TIME 1000 END TIME 1100 <br /> BUCKET MEASURED TO 14 FLU 2 4 2010 <br /> ENVIRONMEN i , L HI:A0 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THISTESTING ' i `'t <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 /> I <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />