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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page f 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 /> 10156819 05/12/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Safeway 2707 <br /> Business Site Address City ZIP Code <br /> 6425 N. Pacific Ave. Stockton 95204 <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 /> Kristopher Bell (408)971-2445 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8833000 10/29/21 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> F.F.#1004933708 <br /> OPW#902968 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines(Specify): <br /> 2 Industry Code or Engineering Standard(Specify): PEI 1200 <br /> ❑Engineered Method(Specify): <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages 1 <br /> TANK ID:(By tank number,stored product,etc.) 1 Regular 2 Prem 3 Diesel <br /> Spill Container Manufacturer: CNI CNI CNI <br /> Method of Cathodic Protection: ®Non-Metallic 2 Non-Metallic 2 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) 13" 13" 13" <br /> Depth of Spill Container:(Inches) 16 1/4" 15 1/2" 15 1/2" <br /> Does the spill container have a 5 gallon capacity? 2 Yes ❑No 2 Yes ❑No 2 Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: 2 Drain Valve 2 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: 2 Pass ❑Fail 2 Pass ❑Fail I 2 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 />