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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type ofAction ❑ Installation Test ❑ Repair Test xQ 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10588471 8/9/ 19 <br /> Business Name (Same as Facility !Name or DBA-Doing Business As) <br /> SAN JOAQUIN GENERAL HOSPITAL - ENGINE PLANT <br /> Business Site Address City ZIP Code <br /> 500 W HOSPITAL RD 7�7FRENCH CAMP , CA 95239 <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 /> EDWARD STEARNS (209 ) 744-0112 <br /> Contractor / Tank Tester License # ICC Certificatlon # IGC Certification Expiration Date <br /> 14- 1760 Ex . 9/30/20 8883080- UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable cerSficadons.) <br /> Franklin Fueling - EBW & Phil Tite #1009893708 Ex. 11 /29/2020 <br /> OPW # 104-635 Ex. 3114/2020 <br /> Ill. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines (Specify); LAKE TEST <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.) RED DIESEL <br /> Spill Container Manufacturer; OPW <br /> Method of Cathodic Protection: 21 Non Metallic <br /> ❑ Non-Metallic ❑ Non-Metalllc ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (specify in V.) ❑ Other (Specifyin v.) ❑ Other (specify in v) ❑ Other (specNy In v.) <br /> Inside Diameter of Spill Container. (inches) 11 <br /> Depth of Spill Container: (inches) 13 <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Drain Valve <br /> ❑ Onstte Pump ❑ Onshe Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) I ❑ Other (Specey in v.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑x Pass ElFail ElPass El Fail Fail ❑ Pass ❑ Fail Pass [IFall <br /> V. COMMENTS <br /> Any items marked `Fail" above must be explained in this section. Any additional comrment&r to elsa�be pravlded here, <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDU bTIN01rf41SjESTJN . <br /> 1 hereby certify that the spill containers were tested in accordance with California Code cif` kbgt#Iatf WS, [,-411tle 23, Division 3, <br /> Chapter 16, Section 2637. 7 and all the information contained herein Is accurate. <br /> UST Service Technician Signature <br /> ff the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = CaN(aNa Enftyrientat Reporting System, ID = Idert icadon, UST = Undergro" Storage Tank, [CC = Interrratianal Code Card <br />