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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 /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181511 08/14/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> KwikSery BW 998 <br /> Business Site Address City ZIP Code <br /> 2501 Jackson Ave . Escalon 95320 <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 /> Eusebio Sousa (707) 545-5522 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Able Maintenance , Inc. - 312844 5254516 7/12/21 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW EVR Phase 1 - UST # 100414 <br /> Ill . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ® Manufacturer Guidelines (Specify): OPW <br /> ❑ Industry Code or Engineering Standard (Specify): <br /> ❑ Engineered Method (Specify): <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages <br /> TANK ID : (By tank number, stored product, etc.) 1 Diesel 2 3 4 <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection : ® Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in 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 /> Method to Keep Spill Container Empty: ® Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> IV. ' SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. <br /> Replaced 91 Diesel Fill Bucket - Tested & Passed . <br /> i <br /> Inspector Shewit Woldearegay on site. <br /> VL 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, <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 may be attached. <br /> CERS = Calffomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />