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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 /> 10146151 05/21 / 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Costco # 1091 Lodi <br /> Business Site Address City ZIP Code <br /> 2680 Reynolds Ranch Parkway . 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 /> Isaac Anderson (209 ) 532 - 7320 Ext, <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Ca 623541 /09 - 1749 8146912 06/ 12/20 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW # 100456 , PhikTite # 1022863709 , ICC Service Technician #8146912 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : <br /> M Manufacturer Guidelines : (Specify) 1 hour Lake Test <br /> ❑ Industry Code or Engineering Standard : (Specify) <br /> ❑ Engineered Method : (Specify) <br /> # of Attached Pages <br /> j Attach the testing procedures and all documentation required to determine the results. <br /> 87A Fill 87B Fill 91 Fill Additive Fill <br />€ Tank ID : (By tank number, stored product, etc.) <br /> t <br /> Spill Container Manufacturer: OPW OPW OPW OPW <br /> ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection M Isolation ® Isolation ® Isolation ® Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container: (Inches) 11 11 11 11 <br /> Depth of Spill Container: (Inches) 14 14 14 14 <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No <br /> kl <br /> i M Drain Valve ® Drain Valve ® Drain Valve ® Drain Valve <br /> Method to Keep Spill Container Empty ElOnsite Pump ElOnsite Pump ElOnsite Pump ElOnsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V) <br /> IV, SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ® Pass ❑ Fail M Pass El Fail ® Pass ❑ Fail ® Pass El Fail <br /> V. COMMENTS <br /> All 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 , chapter 16 , section <br /> 2637 . 1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more component an this form accommodates, additional copies of this page may be attached. <br /> rFRS = rnlifnmin Fnv1mnmenfA RPnnrtinn Svctem. In = Idanfifirafinn. I IST = I lnrinmrnund ctnrnna tank. ICC = Infamntinnal Cnr1a rni mril <br />