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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 /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181407 01/31/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Kwik Sery Lodi <br /> Business Site Address City ZIP Code <br /> 420 W. Kettleman Ln. Lodi 95240 <br /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> Eusebio Sousa (707)545-5522 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Able Maintenance, Inc. -312844 5254516-UT 7/12/21 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW EVR Phase 1-UST Cert# 100414 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑ Manufacturer Guidelines(Specify): `11 <br /> 0 Industry Code or Engineering Standard (Specify): PEI 1200 <br /> ❑ Engineered Method (Specify): ENVIR <br /> a <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> 1 <br /> TANK ID: (By tank number, stored product, etc.) 1 87 2 Diesel <br /> Spill Container Manufacturer: OPW OPW <br /> Method of Cathodic Protection: ®Non-Metallic ® Non-Metallic ❑ 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) 12" 12" <br /> Depth of Spill Container: (Inches) 14" 14" <br /> 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 {a Drain Valve ❑Drain Valve ❑ Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in V) ❑Other(Specify in V) ❑Other(Specify in V.) ❑Other(Specify in V 1 <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: 0 Pass ❑ Fail ® Pass ❑ Fail ❑ 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 /> Installed new 5 gallon 87 and Diesel Direct Bury Fill buckets Tested& Passed. <br /> Inspector Shewit Woldearegay 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 /> 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 />