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r V <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Test N Repair Test ❑ 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180781 03/05/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> United Pacific #5442 <br /> Business Site Address City ZIP Code <br /> 1469 East Hammer Lane Stockton , Ca . 95210 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Leo Rangel ( 916 ) 991 - 1100 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CSLB#803616 8711887 07/22/19 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Pa <br /> t � <br /> tiro <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method <br /> Used : ❑ Manufacturer Guidelines : <br /> (Specify) <br /> N Industry Code or Engineering Standard : PEI / RP - 1200 E N V I H ¢4 , ` <br /> (Specify) <br /> ❑ Engineered Method : <br /> (Specify) <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. 3 <br /> Tank ID : (By tank number, stored product, etc.) T- 1 91 <br /> Spill Container Manufacturer: OPW <br /> N Non =Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> N Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> Method of Cathodic Protection <br /> ❑ Other E] Other ElOther El 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 " <br /> Depth of Spill Container: (Inches) 13 /2" <br /> Does the spill container have a 6 gallon N Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> capacity? <br /> N Drain Valve ❑ Drain Valve ❑ Drain Valve [I Drain Valve <br /> Method to Keep Spill Container Empty ElOnsite Pump E] Onsite Pump ❑ Onsite Pump ElOnsite Pump <br /> ❑ Other [jOther ElOther E] 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 N Pass ElFail ❑ Pass ❑ Fail El <br /> ❑ Fail ❑ ❑ 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 /> 1 Repairs made to TA 91 spill buckets , replaced failing OPW 2100 series with OPW Double Wall Edge . <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 /> Leo Rangel <br /> If the 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 <br />