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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Action 0 Installation Test ❑ Repair Test ® 12 Month Test 1. FACILITY INFORMATION CERS ID Date of Spill Container Test 10156057 05-20 -2019 Business Name (Same as Facility Name or DBA-Doing Business As.) UPS Business Site Address City ZIP Code 1532 North Broadway Stockton 95205 IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the iCC Certification.) Phone # David Pereira (510) 889 - 0908 Ext, Contractorfrank Tester License # IGC Certification # ICC Certification Expiration Date R. L Stevens Co/ 415807 5240739- UT 05/ 18/2020 Spill Container Testing Training and Certifications (List applicable certifications.) Service Tech III . SPILL CONTAINER TESTING INFORMATION Test Method Used : ❑ Manufacturer Guidelines: (Specify) ® industry Code or Engineering Standard: (Specify) PEI/RP 1200 ❑ Engineered Method : (Specify) # of Attached Pages Attach the testing procedures and all documentation required to determine the results. Tank ID: (By tank number, stored product, etc.) T- 1 Diesel Spill Container Manufacturer: OPW ® Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metailic Method of Cathodic Protection ❑ Isolation ❑ Isolation ❑ isolation ❑ Isolation ❑ Other ❑ Other ❑ Other ❑ Other (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) Inside Diameter of Spill Container: (inches) 12', Depth of Spill Container: (inches) 14" Does the spill container have a 5 gallon capacity? ® Yes CI No ❑ Yes ❑ No ❑ Yes ❑ No 0 Yes ❑ No ® Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve Method to Keep Spill Container Empty ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump C1Other ElOther ❑ Other ❑ Other (Specify in section V.) (Specify in section V) (Specify in section V.) (Specify in section V) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results ® Pass © Fail El Pass ❑ Fail El ❑ Fail ❑ Pass ❑ Fail ! V. COMMENTS All items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. Liquid tested for 1 hr at 13 1 /2 "with no loss VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THiS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2637. 1 and all the Information contained herein is urate. USF Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page maybe attached. CERS = California Environmental ReporWV System, ID = idantificadon, UST = Underground storage rank, ICC Intsmadonal Code Courici)