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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 /> 11 . 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 /> ContractorlTank 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 , Phil -Tite # 10228637093 ICC Service Technician #8146912 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : <br /> ® Manufacturer Guidelines : (Specify) 1 hour Lake Test <br /> ❑ Industry Code or Engineering Standard : (Specify) <br /> ❑ Engineered Method : (Specify) <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> 87A Vapor 87B Vapor 91 Vapor Additive Aux <br /> Tank ID : (By tank number, stored product, etc.) <br /> Spill Container Manufacturer: OPW OPW OPW <br /> ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non- Metallic <br /> ® Isolation N Isolation N Isolation N Isolation <br /> Method of Cathodic Protection <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 /> i <br /> Does the spill container have a 5 gallon capacity? N Yes ❑ No N Yes ❑ No N Yes ❑ No N Yes ❑ No <br /> N Drain Valve N Drain Valve N Drain Valve N Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite 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 N Pass ❑ Fail N Pass ❑ Fail N Pass ❑ Fail N Pass ❑ 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 /> CFR.(; = Califnmis Fnvirnnmpntal Rpnnrtinn SVC}P.m. in = Iripntifiratinn. I IST = l Indprorm and Onranp tank. ICC = intpmatinnal Cndp Cnumail <br />