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PG E095 <br />UNDERGROUND STORAGE TANK <br />If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Test ❑ Repair Test ❑x 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Spill Container Test <br />10148345 <br />09/20/2019 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Pacific Gas and Electric Company <br />Business Site Address <br />City <br />ZIP Code <br />4040 West Ln. <br />Stockton <br />95204 <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 />Jarrett Flewellyn (714) 560-8222 <br />Contractor I Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />588098 <br />8028164 <br />2/20/2021 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />OPW - 0174949 - 07/11/2020 <br />lil. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />❑ Manufacturer Guidelines (Specify): <br />Hydrostatic <br />(] Industry Code or Engineering Standard (Specify): PEI RP1200 <br />❑ Engineered Method (Specify): <br />Attach the testing procedures and all documentation required to determine the results. <br /># of Attached Pages <br />TANK ID: (By tank number, stored product, etc.) <br />UNLEADED <br />DIESEL <br />IWASTE OIL <br />Spill Container Manufacturer: <br />OPW <br />OPW <br />OPW <br />Method of Cathodic Protection: <br />❑ Non -Metallic <br />❑ Non -Metallic <br />❑ Non -Metallic <br />❑ Non -Metallic <br />❑x Isolation <br />9 Isolation <br />❑x Isolation <br />R Isolation <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V.) <br />❑ Other (SpecifjinV.) <br />ElOther (Specify in V.) <br />Inside Diameter of Spill Container: (Inches) <br />11.00" <br />11.00" <br />11.00"Depth <br />of Spill Container: (Inches) <br />13.5" <br />12.5" <br />13.5" <br />Does the spill container have a 5 gallon capacity? <br />Rx Yes ❑No <br />[R Yes RNo <br />0Yes <br />R Yes ElNo <br />Method to Keep Spill Container Empty: <br />❑x Drain Valve <br />ZDrain Valve <br />ZDrain ValveR <br />Drain Valve <br />❑ Onsite Pump <br />R Onsite Pump <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Other (Specify in V) <br />❑ Other (Specify in V) <br />R Other (Specify in V.) <br />R Other (Specify in V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: ❑x Pass R Fail 9Pass R Fail ZPass El Fail El Pass E] 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 />All test water was left on site in a drum. <br />E] Check If Action Item(s) Are Present <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 />CERS = California Environmental Reporting System, ID = Identification, UST =Underground Storage Tank, ICC = International Code Council <br />