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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 3) <br /> Type of Action ❑ Installation Test ❑ Repair Test ® 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10182103 05/22/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> United Pacific #5446 <br /> Business Site Address City ZIP Code <br /> 1403 County Club Blvd . Stockton , CA 95204 <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 /> Richard Thomas ( 916 ) 991 - 1100 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CSLB#803616 SWRB#06 - 1672 5254736 11 /03/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW UST Phase 1 EVR cert. #101154 Exp . Date : 02/20/2020 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : <br /> ❑ Manufacturer Guidelines: <br /> (Specify) <br /> ® Industry Code or Engineering Standard : PEI / RP - 1200 <br /> (Specify) <br /> ❑ Engineered Method : <br /> (Specify) <br /> # 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.) T- 1 Diesel T-2 87 T-3 91 T4 Waste Oil <br /> Spill Container Manufacturer: OPW OPW OPW CNI <br /> ® Non -Metallic ® Non-Metallic M Non-Metallic ® Non -Metallic <br /> Method of Cathodic Protection ® Isolation ® Isolation ® Isolation ® Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container: (Inches) <br /> 12 12 " 12 " 12 " <br /> 13 <br /> Depth of Spill Container: (Inches) 12 " 11 3/a" 11 % 14 1/2 " <br /> Does the spill container have a 5 gallon <br /> capacity? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No El Yes ® No <br /> ® Drain Valve ® 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.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ® Pass ❑ Fail ® Pass ❑ Fail ® Pass 0:Faii ❑ 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 /> 1 . T4 Waste Oil spill container is damaged and is torn / cut all around entire container. Recommend <br /> to replace with OPW below grade spill container. <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 /> Richard Thomas <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 Council <br />