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19204310.5 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page i of 1) <br /> Type of Action 0 Installation Test ❑Repair Test 0 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Dale of Spill Container Test <br /> 10339507 11/27/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Arco 7049 <br /> Business Site Address City ZIP Code <br /> 800 E Kettleman Lane Lodi 195240 <br /> It. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certlficallon.) Phone# - <br /> Elodio Sanchez (925) 551-7555 <br /> Contractor/Tank Tester Ucense# [CC Certification# ICC Certification Expiration Dale <br /> 220793 8887127 6/4/2020 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW Tech Cert# 100695 Exp. 10/24/2020 <br /> Ill. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: Q Manufacturer Guidelines(Specify): Hydrostatic, OPW, Tape Measure <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 113:(By tank number,stored product,etc.) 87 Fill T1 91 Fill T2 DSL Fill T3 <br /> Spill Container Manufacturer OPW OPW OPW <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑Q Non-Metallic Q Non-Metallic ❑Non-Metaalc <br /> ❑Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(specify in v.) ❑Other(specify in v) ❑Other(specify M v.) ❑Other(Specify in v.) <br /> Inside Diameter of Spill Container.(inches) 12 12 12 <br /> Depth of Spill Container.(inches) 15 15 15 <br /> Does the spill container have a 5 gallon capacity? 2 Yes ❑No 91 Yes ❑No 21 Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ❑Drain Valve ❑Drain Valve ❑Drain Valve ❑Drain Valve <br /> ❑x Onsite Pump ❑x Onstle Pump 0 Onsite Pump ❑Onslte Pump <br /> ❑Other(specify in v.) ❑Other(Specify In v.) I ❑Other(specify In v) I ❑Other{Specify in v.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: 0 Pass [I Fall 0 Pass ❑Fail 1 0 Pass ❑Fall 1 ❑Pass ❑Fail <br /> V. COMMENTS <br /> Any items marked"Fall"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 Califomla Code of Regulations, Title 23, Division 3, <br /> Chapter 16,Section 2637.1 and all the Informatio9f ontained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more compbnents than this form accommodates,additional copies of this page may be attached. <br /> CERS=Caifornla BT*arvmiW Reporting System.ID=ldertitifK M UST=Underground Storage Tank ICC=International Code Courd <br />