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UNDERGROUND STORAGE TANK <br /> SPILL . TESTING REPORT FORM {Page 1 of 1 ) <br /> Type of Action ❑ Installation Test ❑ Repair Test ❑J 12 Month Test <br /> I , FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181559 6/6/2019 <br /> Business Name (Same as Facilfly Name or OBA-Do(ng Business As) <br /> Kaiser Manteca <br /> Business Site Address City ZIP Code <br /> 1777 W . Yosemite Avenue Manteca CA <br /> li . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as Shown on the ICC Certification.) Phone # <br /> Jeff Badders <br /> Contractor I Tank Tester License 11 ICC Certification # ICC Certification Expiration Date <br /> 808313 5252456 7/28/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> See Attached <br /> Ill. SPiLL, CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify): <br /> WIndustry Code or Engineering Standard (Specify): PEI RP1200 <br /> ❑ Engineered Method (Specify): <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages <br /> TANK ID: (8y tank number, stored product, etc.) Diesel <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection: ❑ NonWetallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> [�] Isolation C] isolation C] Isolation C] Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in K) <br /> Inside Diameter of Spill Container: (Inches) 12 " <br /> Depth of Spill Container: (inches) 14" <br /> Does the spill container have a 5 gallon capacity? W Yes ❑ No ❑ Yes [a No ❑ Yes ❑ No ❑ Yes 0 No <br /> Method to Keep Spill Container Empty: W Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> 0 Other (Specify in V.) Other (Specifyin V) I Other (Specify in V.) 0 Other (Specilyin V.) <br /> IV, SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: W Pass 99 El Fall JL ❑ Pass El Fall ❑ Pass ❑ Fail ❑ Pass El Fall' <br /> r V. COMMENTS <br /> Any items marked "Fall" above must be explained in this section. Any additional comments 1 yto l ts. ,hqro <br /> . ] UN I . <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING T <br /> I hereby certify that the spill containers were tested In accordance with California Code of Regulations, Title 23, Division 30 <br /> Chapter 16, Section 2637. 1 and all the Information contained herein is accurate, <br /> UST Service Technician Signature <br />