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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 /> 5/27/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Short Stop <br /> Business Site Address City ZIP Code <br /> 20 W Turner Rd Lodi 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 /> Chris Adams (209) 461-6337 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1001331 A-HAZ 8230218 9/1/2020 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> EBW 1014863710 Exp:1/31/2022 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: Manufacturer Guidelines(Specify): Hydrostatic <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.) 87 91 <br /> Spill Container Manufacturer: EBW EBW <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑x 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) 16" 1611 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑No E Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ❑Drain Valve ❑Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in V.) El Other(Specify in V.) ❑Other(Specify in V.) El Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑x Pass ❑Fail (]Pass ❑Fail I ❑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 /> 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, Tl.tle 23, Division 3,, <br /> Chapter 16,Section 2637.1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> i' <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 Councflrri RO N M E N TAL HEALTH <br /> DEPARTMENT <br />