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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Action ❑ installation Test ❑ Repair Test 12 Month Test I . FACILITY INFORMATION CERS ID Date of Spill Container Test 10180977 6/6/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Kaiser Stockton Business Site Address City ZIP Cade 7373 West Lane Stockton CA It. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # Jeff Badders Contractor t Tank Tester License # iCC Certification ICC Certification Expiration Date 808313 5252456 7/28/2019 Spill Container Testing Training and Certifications (List applicable certifications) See Attached III. SPiLL CONTAINER TESTING INFORMATION Test Method Used: F] Manufacturer Guidelines (Specify): 1 Visual { W Industry Code or Engineering Standard (Specify): PEI RP1200 ` I (] Engineered Method (Specity): Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK iD : (By tank number, stored product, elc.} Diesel Spill Container Manufacturer: OPW i Method of Cathodic Protection: Non-Metallic ❑ iton-Metallic ❑ iton-Metallic ❑ Non-Metallic [� Isolation [ ] isolation [] Isolation ❑ isolation ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) ❑ Other (Specify in V.) Inside Diameter of Spill Container: (Inches) 12 " Depth of Spill Container: (inches) 14" Does the spill container have a 5 gallon capacity? Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 0 Yes 1:1 No Method to Keep Spill Container Empty: Drain Valve Ej Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Onsite Pump ❑ Onsile Pump ❑ Onsite Pump ❑ Onsite Pump Other (Specify in V) Ll Other (Specify in V) Lj Other (specify in V.) Other (Specify In V.) I IV, SUMMARY OF TESTING RESULTS Spill Container Test Results: Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ )ass ❑ Fail V. COMMENTS Any items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested In accordance with California Code of Regulations , Title 23, Division 3 , Chapter 16, Section 2637. 1 and all the information contained herein is accurate, U8T Service Technician Signature if Nie facility has more components than this farm accommodates, additional copies at this page may be attached. i E '