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UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page f of 1) <br />Type of Action ❑ Installation Test ❑ Repair Test 9 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />10181579 <br />Date of Split Container Test <br />1/24/2020 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />BAGLEY - TRACY UNIFIED SCHOOL <br />Business Site Address <br />1979 W LOWELL AVE <br />City ZIP Code <br />ITRACY,CA 195376 <br />d. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (!Tint as shown on the ICC Caftificadon.) <br />FELIX RAMIREZ <br />Phone # <br />(209) 744-0112 <br />Contractor I Tank Tester License A <br />08-1740 5-31-20 <br />ICC Certification # <br />8883072 -UT <br />ICC Certification Expiration Date <br />11/9/2020 <br />Spill Container Testing Training and Certifications (List applicable certifications) <br />Franklin Fueling - EBW & Phil Tite #1009883708 11/29/20 <br />OPW #104634 3-14-20 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />❑ Manufacturer Guidelines (Specify): <br />x❑ Industry Code or Engineering Standard (Specify): LAKE TEST / PEI <br />❑ Engineered Method (Specify): <br />Attach the testing procedures and aft documentation required to determine the results. <br /># of Attached Pages <br />TANK ID: (By tank number, stored product, etc.) <br />87 <br />DIESEL <br />Spill Container Manufacturer. <br />OPW <br />OPW <br />Method of Cathodic Protection: <br />0 Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in v.) <br />❑x Non-Metalic <br />❑ Isolation <br />❑ Other (Specify in v) <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in v) <br />1 ] Non -Metallic <br />❑ Isolation <br />❑ Other (Specffyin v.) <br />Inside Diameter of Split Container: (inches) <br />11 <br />11 <br />Depth of spill Container: (Inches) <br />133/4 <br />103/4 <br />Does the spill container have a 5 gallon capacity? <br />Q Yes ❑ No <br />I[@ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Method to Keep Split Container Empty: <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in v.) <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in v.) <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify In v.) <br />❑ Drain Valve <br />❑ Onshe Pump <br />❑ Other (Specffy in v.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Teat Results: ❑x Pass ❑ Fail I ❑x Pass [:]Fall <br />❑ Pass ❑ Fail ❑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 />START TIME 1245 END TIME 1345 <br />87 MARKED AT 12" DIESEL MARKED AT 9" <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br />I hereby certify that the spill contalnem 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 j,f� <br />N the facility has more components than this form accommodates, additional copies of this page may be attached. <br />CFRS = Cdbrta E M=rwW Regor" System, ID = ldenitlication, UST= lhidergioud Storage TanK ICC = IrdEmAional Code Counoi <br />