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01 <br />UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action CI Installation Test MI Repair Test 0 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID Date of Spill Container Test <br />11/08/2018 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />Unified Grocers, Inc. <br />Business Site Address <br />1990 Piccoli Rd. <br />City <br />Stockton <br />ZIP Code <br />95215 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the lest (Print as shown on the ICC Certification.) <br />Jarrett Flewellyn <br />Phone # <br />(714) 560-8222 <br />Contractor / Tank Tester License # <br />588098 <br />ICC Certification # <br />8028184 <br />ICC Certification Expiration Date <br />03-29-2019 <br />alp Calner Testing Training and Certifications (List applicable certifications.) <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />Hydrostatic <br />0 Manufacturer Guidelines (Specify): Franklin Fueling INCON TS - STS <br />Industry Code or Engineering Standard (Specify): <br />ID Engineered Method (Specify): <br />Attach the testing procedures and all documentation required to determine the results. # of Attached Pages <br />4 <br />TANK ID: (By tank number; stored plectuct. etc.) Diesel Diesel <br />Spill Container Manufacturer: CN I CNI <br />Method of Cathodic Protection: 0 Non-Metallic <br />II Isolation <br />III Other (Specify in V.) <br />E] Non-Metallic <br />ID Isolation <br />Other (Specify in V.) <br />Non-Metallic <br />Isolation <br />M Other (Specify In V.) <br />El Non-Metallic <br />El Isolation <br />U Other (Specify In V.) <br />Inside Diameter of Spill Container: (Inches) <br />Depth of Spill Container: (Inches) <br />11" 11" <br />13.5" 13.5" <br />Does the spill container have a 5 gallon capacity? El Yes ID No 0 Yes 0 No Yes • No <br />Drain Valve <br />1=1 Onsite Pump <br />I=1 Other (Specify in V.) <br />0 Yes II No <br />0 Drain Valve <br />0 Onsite Pump <br />Ci Other (Specify in V.) <br />Method to Keep Spill Container Empty: 1=1 Drain Valve <br />0 Onsite Pump <br />['Other (Specify In V.) <br />D Drain Valve <br />LI Onsite Pump <br />12 Other (Specify in V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: I 0 Pass 1=I Fail I El Pass 0 Fail I • Pass 0 Fall I 0 Pass 0 Fail <br />V. COMMENTS <br />Any items marked Tail" above must be explained in this section. Any additional comments may also be provided here. <br />All test water was left on site. <br />All test water was removed with a hand pump. <br />Bucket initially failed. Replaced the drain valve and fill cap, test passed. <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 />paroteee ?ewe,* <br />F 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