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19204310.5 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM(Page 1 of 1) <br /> Type ;Adlon x❑Installation Test ❑Repair Test 1@ 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS 1D Date 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 /> 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 /> Elodio Sanchez 1 (925) 551-7555 <br /> Contractor/Tank Tester License# ICC Certification ICC Certification Expiration Date <br /> 220793 1 8887127 6/4/2020 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW Tech Cert#100695 Exp. 10/24/2020 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: 0 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 ID:(By tank number,stored product,eta) 87 Vapor T1 91 Vapor T2 <br /> Spill Container Manufacturer. OPW OPW <br /> Method of Cathodic Protection: ❑x Non-Melallic ❑x Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> ❑Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(Specify In V.) ❑Other(SpecBy In V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container.(inches) 12 12 <br /> Depth of Spill Container.(Inches) 16 16 <br /> Does the spilt container have a 5 gallon capacity? EI Yes ❑No (]Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Method to Keep Split Contalner Empty: ❑Drain Valve ❑Drain Valve ❑Drain Valve ❑Drain Valve <br /> E Onsile Pump I]Onsite Pump ❑Onsile Pump ❑Onsite Pump <br /> ❑Other(Spea9y M V.) 1 ❑Other(Specify In V.) I [:]Other(Specify In V.) ❑Other(Specify In V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑Q Pass []Fall ❑Q Pass ❑Fall ❑Pass ❑Fall ❑Pass Fall <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 testa In accordance with California Code of Regulations, Title 23, Division 3, <br /> Chapter 16,Section 2637.1 and all the Informationfiffitaineg herein Is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components than this rami accommodates,addiWona/copies of this page may be attached. <br /> CERS=CaBforrla Environmental Reporting System,10=Identli akm UST=Underground Storage Tank,ICC=lnterrratiorral Code Co xid <br />