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' � ,I V D <br /> . <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM 'ARONMENTAL HEALT E: <br /> - rr <br /> Type of Action ❑Installation Test ® Repair Test ❑ 12 Month Test NIT <br /> I. FACILITY INFORMATION <br /> CERS ID: Date: <br /> 11/27/2019 <br /> Business Name <br /> Arco AmPm Cherokee Lane <br /> Business Site Address City Zip Code <br /> 900 S Cherokee Lane Lodi <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Business Name&Address: BZ Service Station Maintenance—1041 Triangle Ct,West Sacramento CA <br /> Name of UST Service Technician Performing the Test Rob Jacobs Phone# 916-371-2380 <br /> Contractor License# 433159 ICC Certification# 9943 ICC Expiration Date 5/10/2020 <br /> Spill Container Testing Training and Certification (List applicable certification.) <br /> OPW AST/UST-177621 ex 4/2/21 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer(Specify): <br /> ®Industry Code or Engineering Standard(Specify): PEI 1200 Pg.11 <br /> Hydrostatic Engineered Method(Specify): <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages: <br /> TANK ID:(By tank fit,stored product,etc) DSL <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection: ® Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> Inside Diameter of Spill Container:(Inches) ill. <br /> Depth of Spill Container:(Inches) 13" <br /> Does the spill container have a 5 gallon ® Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> capacity? <br /> Method to Keep Spill Container Empty: ® Drain Value ❑ Drain Value ❑ Drain Value ❑ Drain Value <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ® Pass ❑ Fail I El 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 /> Tested DSL bucket with county post construction. <br /> V1. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hearby certify that the spill containers were tested in accordance with California Code of Regulations,Title 23,Division 3,Chapter 16,Section <br /> 2637.1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br />