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UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Test leg Repair Test ❑ 12 Month as <br />I. FACILITY INFORMATION <br />CERS ID Date of Spill Container Test <br />'? - (! -a / <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />(y) Phi-�Vfe CA R*ee` <br />Business Site Address City ZIP Code <br />S, tli � S 4? <br />II. UNDERGROUND STORAGE TANK SERVICE ECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on fhe ICC Certcation.) Phone # <br />Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />r It me. <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: 19ManufacturerGuidelines (Specify): ' <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the testing procedures and al! documentation required to determine the results. <br />TAN K ID: (By tank number, stored pro <br />duct, etc.) <br />Spill Container Manufacturer: <br />Method of Cathodic Protection: <br />Inside Diameter of Spill Container: (Inches) <br />Depth of Spill Container: (Inches) <br />Does the spill container have a 5 gallon capacity? <br />Method to Keep Spill Container Empty: <br />Spill Container Test Results: <br />items marked "Fat!" above must <br />Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />14h // <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specifyin V.) <br />Yes ❑ No ❑Yes ❑ No <br />Drain Valve ❑ Drain Valve Drain <br />❑ Onsite Pump ❑ Onsite Pump <br />❑ Other (Specify in V.) [I Other (Specify in V.) <br /># of Attached Pages <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑Yes ❑ Na <br />❑ Valve <br />E] Onsite Pump <br />❑ O <br />SUMMARY OF TESTING RESULTS <br />ther (Specify in V. <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑ Yes ❑ No <br />❑ Drain Valve <br />❑ <br />site Pump <br />❑ Other (Specify in V.) <br />EMEN <br />IV. <br />Pass ElFail ❑ Pass ❑ Fail LiPass ❑Fail ❑Pass ❑Fail <br />V. COMMENTS <br />explained in this section. Any additional comments may also be provided here. <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 an rTe information contained herein is accurate. <br />UST Service Teghn cWh Signat4riif /F <br />the fac' ' ha re than this form accommodates, additional copies of this page maybe <br />CERS = CaGfomia Environmental Reporting System, ID =Identification, UST =Underground Storage Tank, ICC = International Code Coundl <br />