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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 Z 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181313 11/27/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> LODI FOOD & LIQUOR <br /> Business Site Address City ZIP Code <br /> 1225 W. LOCKEFORD STREET LODI, CA 95240 <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 /> ZANE NIMMO (209) 744-0112 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 04-1676 Ex. 3/31/22 8883064-UT 6/1/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> Franklin Fueling - EBW& Phil Tite #10009843708 Ex.11/16/2018 <br /> OPW#104-632 Ex. 3/14/2020 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): O P W PHASE I LAKE TESTING <br /> ❑ Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> TANK ID: (By tank number, stored product, etc.) 1 - 87 OCT 2 - 91 OCT 3 - DIESEL <br /> Spill Container Manufacturer: O P W O P W O P W <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic ❑x 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) 11 1/2 11 1/2 11 1/2 <br /> Depth of Spill Container: (Inches) 12 1/2 12 1/2 13 1/2 <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No 111 Yes ❑ No 0 Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ❑x 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.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: i ❑x Pass ❑Fail 0 Pass ❑Fail ❑x 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 /> REU., _ ED <br /> I-tb 2 4 2020 <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCT1N,f:THIS TESTIN HEALTH <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations,_Title 11.1-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 />