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If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br />CERS = California Environmental Reporting System, ID = Identification, UST =Underground Storage Tank, ICC = International Code Coundl <br />III iiiiiiiiiiiiiii IN <br />UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Test ❑ Repair Test ❑x 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Spill Container Test <br />10/22/2018 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />ST. JOSEPH'S HOSPITAL <br />Business Site Address City <br />ZIP Code <br />1800 N CALIFORNIA ST. STOCKTON, CA <br />95204 <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 />Zane Nimmo (209) 744-0112 <br />Contractor I Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />04-1676 Ex. 3/31/19 <br />8883064-UT <br />6/1/2019 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tite #10009843708 Ex. 11/16/2018 <br />OPW #104-632 Ex. 3/14/2020 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />❑x Manufacturer Guidelines (Specify): E B W / FRANKLIN FUELING LAKE TESTING <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br /># of Attached Pages <br />Attach the testing procedures and all documentation required to determine the results. <br />TANK ID: (By tank number, stored product, etc.) <br />RED DSL <br />Spill Container Manufacturer: <br />E B W <br />Method of Cathodic Protection: <br />❑x Non-Metallic <br />❑ Non-Metallic <br />❑ Non-Metallic <br />❑ Non-Metallic <br />❑ Isolation <br />❑ Isolation <br />❑ Isolation <br />❑ Isolation <br />❑ Other (specify in V.) <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V) <br />❑ Other (Specify in V.) <br />Inside Diameter of Spill Container: (Inches) <br />12 <br />Depth of Spill Container: (Inches) <br />12 1/2 <br />Does the spill container have a 5 gallon capacity? <br />❑ Yes ❑x No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Method to Keep Spill Container Empty: <br />❑x Drain Valve <br />❑ Drain Valve <br />❑ Drain Valve <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: <br />❑x Pass El El P:11ass El Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />V. COMMENTS <br />Any items marked "Fail" above must be explained in this section. Any additional comments may e r Viffq i rye <br />THIS SPILL BUCKET MEASURES JUST UNDER FIVE GALLONS. <br />1 V Y 6 2018 <br />ENVIRONM NT <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING <br />I hereby certify that the spill containers were tested in accordance with California Code of Regulations, Title 3, 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 maybe attached. <br />CERS = California Environmental Reporting System, ID = Identification, UST =Underground Storage Tank, ICC = International Code Coundl <br />