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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM(page 1 of 1) <br /> Type of Action ®Installation Test ❑Repair Test ❑ 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10151579 4/17/19 <br /> Business Name(Same as Facih7y Name or DBA-Doing Business As.) <br /> Tracy Unified School District <br /> Business Site Address City ZIP Code <br /> 1975 W Lowell Ave I Tracy 95376 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC CeAftetlon.) Phone# <br /> Eric Molgaard (209) 367-4800 Ext. <br /> Contractor Tank Tester License# ICC Certification# ICC Certification E)TIratlon Date <br /> 774802 8881020 2/25/2021 <br /> Spill Container Testing Training and Certificatlons(List applicable eertiftell ns.) <br /> OPW <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ` 9 2019 <br /> ®Manufacturer Guidelines:(Specify) OPW A N f i f <br /> ®Industry Code or Engineering Standard:(Specify) PEI/RP 1200-17 <br /> ENVIRONMENTAL HEA H <br /> ElEngineered Method:(Spedty) <br /> n�PARTNAENT <br /> Attach the testing procedures and all documentat/on required to determine the results. #of Attached Pages <br /> Tank ID:(By tank number,stored product,etc.) 25210/DSI/10k <br /> Spill Container Manufacturer: OPW <br /> ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> Method of Cathodic Protection ®Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Spedly in section V.) (Specify in secbm V.) (Specify in"c#on V.) I (Spedly in section V.) <br /> Inside Diameter of Spill Container.(inches) 12 <br /> Depth of Spill Container:(inches) 13 <br /> Does the spill container have a 5 gallon capacity? ®Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> ®Drain Valve ❑Drain Valve ❑Drain Valve ❑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 sec#on V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ®Pass ❑Fail 1 ❑Pass ❑Fall I ❑Pass ❑Fail TO Pass ❑Fail <br /> V. COMMENTS <br /> A#items marred'Fair above must be explained In this section.Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the spill containers were bestedI accordance with Callfomia Code of Regulations,title 23,division 3,chapter 16,section <br /> 2637.1 and all the Information contained urate. <br /> UST Service Technician Sign <br /> M the facility has more arrts than this form accommodates,additional copies of this page may be attached. <br /> CERS=CaMomla Fmiromrertal Reporting Sim,ID=Identification,UST-Underground storage tank,ICC=International Cods Council <br />