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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 Q 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 3/9/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> FLAG CITY SHELL <br /> Business Site Address City ZIP Code <br /> 6437 W BANNER ST 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 /> David Winkler (209 ) 744 - 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 1 <br /> 08- 1739 Ex . 3/31 /20 8883059 - UT 1 /29/2020 <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 INFORMATION <br /> Test Method Used : Z Manufacturer Guidelines (Specify): WATER TEST <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 91 DSL <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑x Non-Metallic 0 Non-Metallic X 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) 12 12 12 <br /> Depth of Spill Container: (Inches) 14 15 14 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No El Yes ❑ No El Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: R Drain Valve ❑x Drain Valve ❑x 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 : 0 Pass ❑ Fail ❑x Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ 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 W <br /> If the facility has more components than this 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 />