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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 /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10154767 07-30-2019 <br /> Business Name (Same as FacilityName or DBA-Doing Business As) <br /> Lawrence Livermore ational Laboratory Bldg . 879 <br /> Business Site Address City ZIP Code <br /> 15999 West Corral Hollow Road Tracy 95376 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Brian Thornton 209-834-0792 <br /> Contractor / Tank Tester license # ICC Certification # ICC Certification Expiration Date <br /> CSLB A , C- 10 , HAZ #724513 502496MC 03 -26-2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications) <br /> Caldwell Sump Level Change Indicator Exp. 05-22-2020 <br /> 111. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ® Manufacturer Guidelines (Specify): <br /> ® Industry Code or Engineering Standard (Specify): On 1 gph Hydrostatic testing <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.) <br /> Spill Container Manufacturer: <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) 1 1200" <br /> Depth of Spill Container: (Inches) 12 * 50" 12a75 " <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 19 Drain Valve ❑ Drain Valve <br /> ❑ 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 /> Using Caldwell Sump Level Change Indicator <br /> Unleaded from 10 :31a @ 12 .00" to 11 :01a @ 12. 00" = 0.00 change. Pass <br /> Diesel from 11 : 12a @ 12 . 25" to 11 :37a @ 12. 25" = 0.00 change . Pass <br /> SJEHD on site . <br /> Vi. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the spill containers were tested in accordance with Califomia 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 = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br /> UN408 www.unidoes.org 1 /1 - Rev. 06/14/18 <br />