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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Test ❑X Repair Test ❑ 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 6/22/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Fast Lane <br /> Business Site Address City ZIP Code <br /> 116 Roth Rd Lathrop 95330 <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/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 /> OPW Installer# 100305 EXP: 5/23/2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines(Specify): <br /> ❑x Industry Code or Engineering Standard(Specify): 1 hr Hydrostatic Test <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.) Diesel South Diesel North <br /> Spill Container Manufacturer: OPW OPW <br /> Method of Cathodic Protection: Q 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 1/2" <br /> Depth of Spill Container:(Inches) 15 3/4" 15 3/4" <br /> Does the spill container have a 5 gallon capacity? E Yes ❑No I]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: ❑X Pass ❑Fail (]Pass ❑Fail 1 ❑Pass ❑Fail ❑Pass ❑Fail <br /> V. COMMENTS <br /> Any items marked"Fail'above must be explained in this section. Any additional com n a d b tfillit <br /> JUIN � 6 2020 <br /> t�!V!RON�/!ENTAi__ HEALTH <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTI14GrrKf61_T1 TING <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 conta' ed herein is accurate. <br /> UST Service Technician Signature y/ / <br /> If the facility has more components tha form accommodates,additional copies of this page may be attached. <br /> CERS=Califomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank ICC=International Code Council <br />