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UNDERGROUNDSTORAGETANK <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 /> 10156819 09/23/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Safeway 2600 <br /> Business Site Address City ZIP Code <br /> 1987 W 11 th St. Tracy 95376 <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 /> Kristopher Bell (408)971-2445 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8833000 7/22/20 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> F.F.# 1004933708 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑ Manufacturer Guidelines(Specify): <br /> ® Industry Code or Engineering Standard (Specify): PEI 1200 <br /> ❑ Engineered Method (Specify): <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages1 <br /> TANK ID: (By tank number, stored product, etc.) 1 Regular 2 Prem 3 Diesel i4 <br /> Spill Container Manufacturer: Phil-Tite Phil-Tite Phil-Tite <br /> Method of Cathodic Protection: ® Non-Metallic ® Non-Metallic ® Non-Metallic ❑ Non-Metallic <br /> ❑ 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) 13" 13" 13" <br /> Depth of Spill Container: (Inches) 16 1/2" 15 1/2" 15" <br /> Does the spill container have a 5 gallon capacity? ©Yes ❑ No ©Yes ❑No ✓❑Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: 0 Drain Valve ®Drain Valve ® Drain Valve ❑ Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <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: ® Pass ❑Fail ® Pass ❑ Fail I Wj 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 /> Installed second o-ring on Premium Tank due to leaking during Bucket Test-Tested & Passed. <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, <br /> Chapter 16,Section 2637.1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <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=Intemabonal Code Council <br />