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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 /> 10154767 07-30-2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Lawrence Livermore National Laboratory Bldg . 882 <br /> Business Site Address - 777City I 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 5024962- UC 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 /> 19 Industry Code or Engineering Standard (Specify): 0 . 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.) Diesel <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 inV.) El Other (Specify in V.) [I Other (Specify in V.) [I Other (Specify in v) <br /> Inside Diameter of Spill Container: (Inches) <br /> Depth of Spill Container: (Inches) - <br /> Does the spill container have a 5 gallon capacity? ® Yes ElNo ❑ ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ® Drain Valve ❑ Drain Valve <br /> ❑ Drain Valve El Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in v.) I ❑ Other (Specify in v) I [:] 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 from 9 :40a @14 . 50" to 10 :02a @ 14.50" = 0. 00 change . Pass <br /> SJEHD on site. <br /> R E <br /> yj <br /> ii . <br /> 9 <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 39 <br /> Chapter 16, Section 2637. 1 and all the information contained herein is accurate. E NIV1 t� N M i � € ,=� 1 s ._. s <br /> UST Service Technician Signature ] ✓,�% $" e_ € , -; i FN <br /> l <br /> If the facility has more components than thls form accommodates, additional copies of this page may be attached. <br /> CERS = California Environmental Repor§V System, ID = IdenWation, UST = Underground Storage Tank, ICC = International Code Cour d <br /> UNA08 www.unidocs.org 111 - Rev. 06/14/18 <br />