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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 /> L FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10156819 06/18/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Safeway <br /> Business Site Address City ZIP Code <br /> 1987 W . 11th 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 /> Steven Parmenter 1 (408 ) 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8818846 2/24/21 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> PhikTite 1002603708 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> ® Industry Code or Engineering Standard (Specify) : PEW200 <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.) 1 Regular 2 Prem 3 Diesel <br /> Spill Container Manufacturer: PhikTite PhikTite Phil-Tite <br /> Method of Cathodic Protection: ® Non-Metallic 0 Non-Metallic 0 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) 16 . 00 in . 16 .00 in . 16 . 00 In . <br /> Depth of Spill Container: (inches) 14.00 in . 14 .00 in . 14. 00 In . <br /> j Does the spill container have a 5 gallon capacity? ❑ Yes © No ❑ Yes ® No ❑ Yes © No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ® Drain Valve ® Drain Valve 0 Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br />[ ❑ Other (Specifyin 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 ® Fall ❑ 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 /> VI . CERTIFICATION 13Y 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 = International Code Council <br />