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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM <br /> Type of Action ❑ Installation Test ❑ Repair Test Fol 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180781 8-6-2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> United Pacific # 5447 <br /> Business Site Address City ZIP Code <br /> 1469 East Hammer Lane Stockton 95210 <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 /> Garrett Warren 1 ( 916 ) 991 - 1100 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CSLB#803616 8185019 10-2-2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW & 5 -2021 EVR 101018 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method <br /> Used : El Manufacturer Guidelines : <br /> (Specify) <br /> 9 Industry Code or Engineering Standard : RP 1200 <br /> (Specify) <br /> ❑ Engineered Method : <br /> (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.) T1 91 T2 89 T3 87 Diesel <br /> Spill Container Manufacturer: OPW OPW OPW OPW <br /> ❑o Non-Metallic X Non-Metallic limil Non -Metallic I] Non-Metallic <br /> Method of Cathodic Protection Isolation IR Isolation WE isolation XIsolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container: (Inches) 12 12 12 12 �� <br /> Depth of Spill Container: (Inches) 13 . 75" 14 13 14 . 50" <br /> Does the spill container have a 5 gallon In Yes ❑ No an Yes ❑ No E Yes ❑ No El Yes ❑ No <br /> capacity? <br /> Drain Valve 0 Drain Valve Q Drain Valve X Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section v.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results 9 Pass ❑ Fail I N Pass ❑ Fail ❑ Pass X Fail ❑ Pass M Fail <br /> V. COMMENTS <br /> All items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. <br /> 87 & Diesei spill bucket failed Hydrostatic testing . Will require saw cut and break out on return trip . <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, chapter 16, section <br /> 2637. 1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more component an this form accommodates, additional copies of this page may be attached. <br /> jCERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council <br />