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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 12/21 /2018 Business Name (Same as Facility Name or DBA-Doing Business As) Interstate A Enterprise Inc dba City Food & Liquor Business Site Address City ZIP Code 16470 Cambridge Dr Lathrop 195330 IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN ,INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # Joe Bartholdi ( 209 ) 461 -6337 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 1001331 A-HAZ 00042842 11 /8/2020 Spill Container Testing Training and Certifications (List applicable certifications.) OPW 100782 III . SPILL CONTAINER TESTING INFORMATION ' Test Method Used: ❑ Manufacturer Guidelines (Specify): ❑x Industry Code or Engineering Standard (Specify): HYDROSTATIC TEST ❑ Engineered Method (Specify): Attach the testing procedures and all documentation required to determine the results. 71 # of Attached Pages TANK ID : (By tank number, stored product, etc.) 87 91 Diesel Spill Container Manufacturer: OPW OPW OPW Method of Cathodic Protection: ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic N/A ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify In V.) ❑ Other (Specify in v.) Inside Diameter of Spill Container: (Inches) 11 3/4 " 113/4 It 11 3/4 " Depth of Spill Container: (inches) 15 " 15 15" Does the spill container have a 5 gallon capacity? EI Yes ❑ No FAI Yes ❑ No 2 Yes ❑ No ❑ Yes ❑ No Method to Keep Spill Container Empty: x❑ Drain Valve [H] Drain Valve 9 Drain Valve ❑ Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Other (Specify Inv) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V,) IV. SUMMARY DETESTING RESULTS ' Spill Container Test Results : 0 Pass ❑ Fail N Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked 'Fail' above must be explained in this section. Any additional comments may also be provided here. VIX 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 accurate. UST Service Technician Signature � r�L��2.CfLB t�G If the facility has more components tha is form accommodates, addttionet copies of this page maybe attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council