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01 <br />UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) I <br />Type of Action 0 Installation Test CI 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 Test (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 />8028164 <br />ICC Certification Expiration Date <br />03-29-2019 <br />all C4)86aper Testing Training and Certifications (List applicable certifications.) <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />Hydrostatic <br />ID Manufacturer Guidelines (Specify): Franklin Fueling INCON TS - STS <br />1:1 Industry Code or Engineering Standard (Specify): <br />1:1 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 product, etc.) Diesel Diesel <br />Spill Container Manufacturer: CN I CNI <br />Method of Cathodic Protection: MI Non-Metallic <br />Isolation <br />0 Other (Specify in V.) <br />0 Non-Metallic <br />0 Isolation <br />Other (Specify in V.) <br />0 Non-Metallic <br />ID Isolation <br />1:1 Other (Specify in V.) <br />0 Non-Metallic I <br />0 Isolation <br />I=1 Other (Specify in v.) <br />Inside Diameter of Spill Container: (Inches) 11" 11" <br />Depth of Spill Container: (Inches) 13.5" 13.5" <br />Does the spill container have a 5 gallon capacity? In Yes IN No Yes 0 No Yes CI No Yes • No <br />Method to Keep Spill Container Empty: El Drain Valve <br />CI Onsite Pump <br />0 Other (Specify in V.) <br />E Drain Valve <br />0 Onsite Pump <br />i=j Other (Specify /n V.) <br />I=1 Drain Valve <br />D Onsite Pump <br />0 Other (Specify in V.) <br />D Drain Valve <br />0 Onsite Pump <br />1:1 Other (Specify in V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: , 0 Pass 0 Fail 1 0 Pass 0 Fail 0 Pass E Fail II 0 Pass 0 Fail <br />V. COMMENTS <br />Any items marked 'Fair 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 />AvinetX ?eeeiseeteps <br />_ . _ ... . e 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