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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Test ❑ Repair Test ❑x 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180623 3/30/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> RUPI - COUNTRYSIDE LIQUOR & GAS <br /> Business Site Address City ZIP Code <br /> 14971 N HWY 88 7LODI, 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 /> DAVE WINKLER (209) 744-0112 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 Ex.3/31/20 8883059-UT 1/27/2022 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> Franklin Fueling - EBW& Phil Tite #10009853708 Ex. 11/29/20 <br /> OPW#104-633 Ex. 3/14/2020 <br /> III. SPILL CONTAINER TESTING INFORMA O <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): WATER TEST MAY 1 2 21120 <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): ENVIR0NN,1f-_N1T,A,I_ HEALTH <br /> ;T <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 DSL <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: 0 Non-Metallic 0 Non-Metallic 0 Non-Metallic ❑Non-Metallic <br /> ❑ Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(Specify in V.) ❑Other(Specffyin V) ❑Other(Specifyin V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container:(Inches) 12 12 12 <br /> Depth of Spill Container:(Inches) 14 14 13 <br /> Does the spill container have a 5 gallon capacity? Eil Yes ❑No ❑x 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.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: FF❑x Pass ❑Fail 9Pass [:]Fail 11 ZPass ❑ Fail ❑Pass E]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, 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 />