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i <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action ElInstallation Test ❑ Repair Test Q 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Business Site Address <br /> City ZIP Code <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certlfication.) Phone # <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify): <br /> ❑ Industry Code or Engineering Standard (Specify): <br /> ❑ Engineered Method (Specify): <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> TANK ID : (By tank number, stored product, etc.) Racing Fuel <br /> Spill Container Manufacturer: <br /> Method of Cathodic Protection: ❑ Non-Metallic ❑ Nan-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> 0 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) <br /> 12 " <br /> Depth of Spill Container: (Inches) 14 . 375 " <br /> Does the spill container have a 5 gallon capacity? El Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No El YeslValve <br /> Method to Keep Spill Container Empty: 0 Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drai❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Ons <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 : El Pass ❑ Fail ❑ Pass ❑ Fail El Pass ❑ Fail El 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 /> JUN 2 2019 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN TINC3' Hl <br /> 1 hereby certify that the spill containers were tested in accordance with California Code- !of �t®gl1016n0,Ejit1 23, Division 3, <br /> Chapter 16 , Section 2637 . 1 and all the information contained herein is accurate . <br /> UST Service Technician Signature y /Gr 1d2 <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 />