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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Pagel 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 /> 10181401 6/29/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> VAN DE POL - LODI PACIFIC PRIDE - DSL <br /> Business Site Address City ZIP Code <br /> 351 N. BECKMAN ROAD LODI, CA 195240 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certfcation.) 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.11/29/2020 <br /> OPW#104-632 Ex. 3/15/2022 <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.) 87 OCTANE 91 OCTANE <br /> Spill Container Manufacturer: O P W O P W <br /> Method of Cathodic Protection: 0 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) 11 11 <br /> Depth of Spill Container:(Inches) 12 14 <br /> Does the spill container have a 5 gallon capacity? El Yes ❑No 2 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: ZPass ❑ Fail 9Pass ❑Fail 11 [:1Pass Elail E1 Pass El Fail <br /> V. COMMENTS <br /> Any items marked"Fail'above must be explained in this section. Any additional comments mrW p> k 14er ;VE <br /> JULNEC <br /> L) <br /> 0 8 2020 <br /> ENVIRONMENTAL HEALTH <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING <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 />