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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 /> Date of Sp 11 Contain r Test <br /> CERS ID <br /> d <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> 1 <br /> A h I L�Wo ni <br /> City ZIP Code <br /> Business Site Address G 9 1 <br /> I. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# I <br /> � �6, ( 7�� Ext._71 I <br /> Contractor/Tank Tester License# ICC Certification#, ICC Cerlifi atio E`xvp�oiration Date <br /> 391 �'/ 5-63 zb <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> vo <br /> 111. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑Manufacturer Guidelines:(Specify) f l <br /> industry Code or Engineering Standard:(Specify) <br /> ❑Engineered Method: (Specify) <br /> #of Attached Pages j <br /> Attach the testing procedures and all documentation required to determine the results. <br /> Tank ID: (By tank number,stored product,etc.) <br /> Spill Container Manufacturer: I ,' <br /> ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> c <br /> ❑Isolation ❑ Isolation ❑Isolation ❑Isolation ; <br /> Method of Cathodic Protection ❑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) 13 2 f 3 Z <br /> Depth of Spill Container:(inches) r r Z <br /> Does the spill container have a 5 gallon capacity? ,® ❑Yes No Yes [I No El Yes <br /> ❑No El Yes El No <br /> JR Drain Valve E9 Drain Valve ❑Drain Valve ❑Drain Valve <br /> Method to Keep Spill Container Empty ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑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 :g Pass 'ail Pass ❑Fail ❑Pass ❑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 /> ® 1 1 V 1 <br /> VL CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 1 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. LN V i i O N(VI`i� i AL- h <br /> tj-�Ll iii <br /> UST Service Technician Signature DEPARTMENT <br /> !f the facility has more components t this form accommodates,additional copies of this page may be attached. <br /> rFRS=ralifnmia Fnvimnmanfal RAnnrfinn SvmtAm.In=ldnnlifiratinn.1IRT_1 rnrfAmmiinti%fnram tank.Irr=Intamatinnal rndn rniinril <br />