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U E058 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Test ❑Repair Test Z 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181547 02/10/2020 <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 /> Jarrett Flewellyn <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 588098 8028164 2/20/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> Phil Tite- 1032363709- 11-11-2021 <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) 11.00" <br /> Depth of Spill Container:(Inches) 14.50" <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: ❑x Pass ❑Fail ❑Pass ❑Fail E] Pass ❑Fail El 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 /> All test water was returned to the TAIT shop. <br /> ❑ 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 /> 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 />