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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 /> 10749253 3/ 13/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Costco #038 Stockton <br /> Business Site Address City ZIP Code <br /> 1630 E . Hammer Ln . 771 Stockton 95210 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the /CC Certification.) Phone # <br /> Chad White (209 ) 532 - 7320 Ext. <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Ca623541 /09- 1747 8152115 2/23/2018 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Phil Tite # 1015593710 , ICC Service Technician #8152115 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : <br /> ® Manufacturer Guidelines : (Specify) 1 hour Lake Test <br /> ❑ Industry Code or Engineering Standard : (Specify) <br /> ❑ Engineered Method : (Specify) <br /> # <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.) 87a Fill 87b Fill 91 FIII Additive Fill <br /> Spill Container Manufacturer: Phil Tite Phil Tite Phil Tite OPW <br /> ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection M 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) 10 . 75 10 . 75 10 . 75 11 <br /> Depth of Spill Container: (Inches) 14 14 14 14 <br /> Does the spill container have a 5 gallon capacity? ❑ Yes ® No ❑ Yes M No ❑ Yes M No ® 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 ❑ Fail ® 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 /> 87a , 87b and 91 buckets passed the 1 Hour lake test however did not hold 5 gallons . This addressed 2 years <br /> ago by the CUPA but only issued a letter until a failure . When the updated title 23 was adopted in October it <br /> changed the way the County looks as the requirement . <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 /> i <br /> UST Service Technician Signature <br /> too <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 />