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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 [E 12 Month Test <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181291 9/ 16/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Bank Of Stockton <br /> Business Site Address City ZIP Code <br /> 1941 Lockheed Ct Stockton 95206 <br /> It. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the iCC Certification) Phone # <br /> Elite IV Contractors 1 (209 ) 461 -6337 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1001331 A- HAZ 8230218 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 111 . SPILLCONTAINERTESTING INFORMATION <br /> Test Method Used : E]x Manufacturer Guidelines (Specify): Hydrostatic <br /> ❑ Industry Code or Engineering Standard (Specify): <br /> ❑ Engineered Method (Specify): <br /> # <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.) Jet A <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection: ❑x 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) 101 /2 <br /> Depth of Spill Container: (inches) 16° <br /> Does the spill container have a 5 gallon capacity? El Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: 0 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: l 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 /> Perform 1 hour hydrostatic test, spill container held 5 gallons - passed <br /> VL CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING ' <br /> 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 = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Coundl <br />