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UE058 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page-I 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 /> 10181547 02/11/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Pacific Bell Telephone Co. dba AT&T California <br /> Business Site Address City ZIP Code <br /> 10 E. 12th St. Tracy 95376 <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 /> Gage Hart (714)560-8222 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 588098 8361014 06/12/2019 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> Phil-Tite <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑ Manufacturer Guidelines(Specify): <br /> Hydrostatic <br /> ❑x Industry Code or Engineering Standard(Specify): PEI RP1200 <br /> ❑ Engineered Method(Specify): <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> TANK ID: (By tank number, stored product, etc.) UE0580002 <br /> Spill Container Manufacturer: Phil-Tite <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(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 11" <br /> Depth of Spill Container: (inches) 114.5" <br /> Does the spill container have a 5 gallon capacity? 0 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: TF_X Pass ❑ Fail ❑ Pass ❑Fail 11 ❑ Pass ❑ Fail 11 ❑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 /> E] Check If Action Item(s)Are Present <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 /> 5 w Maar <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 />