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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM <br /> Type of Action ❑ Installation Test ❑ Repair Test 0 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181557 01 /03/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> VALLEY PACIFIC CHARTER WAY CARDLOCK <br /> Business Site Address City ZIP Code <br /> 1501 West Charter Way Stockton 95206 <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 /> Garrett Warren (916 ) 991 - 1100 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CSLB#803616 SWRB#06 -1672 8185019 10 -2-2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW EVR 101018 exp . 6- 9 -2019 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method <br /> Used : F'1 Manufacturer Guidelines: <br /> (Specify) <br /> ® Industry Code or Engineering Standard : RP 1200 <br /> (Specify) <br /> ❑ Engineered Method : <br /> (Specify) <br /> j # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. 3 <br /> Tank ID : (By tank number, stored product, etc.) T1 : 87 T2 : Diesel <br /> Spill Container Manufacturer: OPW OPW <br /> 0 Non -Metallic X Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection Isolation <br /> ME Isolation El Isolation ❑ Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) (Specifyin section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container: (Inches) <br /> Depth of Spill Container: (Inches) 14 . 00° 14 . 00° <br /> Does the spill container have a 5 gallon Fil Yes ❑ No (] Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> capacity? <br /> Drain Valve on 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.) (Specifyin section V.) (Specif ( in section V.) (Specifyin section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results X Pass 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 /> 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 /> UST Service Technician Signature <br /> If the facility has more compone s t*V2c6othmodates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council <br />