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t <br /> 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 /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10166191 05/30/ 19 <br /> Business Name (Same as Facility Name or DBA -Doing Business As.) <br /> Hammer 1 -5 Arco <br /> Business Site Address City ZIP Code <br /> 3201 W . Hammer Lane Stockton 95209 <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 /> Isaac Anderson (209 ) 532 - 7320 Ext, <br /> ContractorfTank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CA 623541 /09 - 1 749 8146912 06/ 12/20 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW # 100456 exp 05/ 15/20 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : <br /> ® Manufacturer Guidelines : (Specify) 1 Hour Lake Test <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 /> I <br /> Tank ID : (By tank number, stored product, etc.) 87A Syphon Fill 87B Master Fill 91 Fill <br /> Spill Container Manufacturer: O PW O PW O PW <br /> ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> i <br /> Method of Cathodic Protection ® Isolation ® Isolation ® Isolation El Isolation <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) 10 . 75 10 . 75 10 . 75 <br /> Depth of Spill Container: (Inches) 14 14 14 <br /> Does the spill container have a 5 gallon capacity? M Yes ElNo ® Yes ElNo ® Yes ElNo ElYes F1No <br /> ® Drain Valve ® Drain Valve ® Drain Valve ❑ Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump EIOnsite Pump ElOnsite Pump ElOnsite 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 ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ 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 /> r <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 /> � i i I . rl <br /> UST Service Technician Signature <br /> If the facility has more compone than this form accommodates, additional copies of this page may be attached. <br /> CFR.(; = Califnmin FnvimnmanfA Rennrfinn Svctem. in = Idantifirafinn. I IST = I Indpmmiind cfnrnna tank. ICC = Infemntinnal Cnde Crnmril <br />