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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑x Installation Test ❑ Repair Test ❑ 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 6/4/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Lodi 76 <br /> Business Site Address City ZIP Code <br /> 141 E Harney Ln 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 /> Steve Jones ( 916 ) 205- 1537 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 768938 6205 6/21 /2021 <br /> Sill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW EVR Phase 1 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : El Manufacturer Guidelines (Specify) : 1 Hr Hydrostatic <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.) Regular Premium Diesel <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection : ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑x Isolation 0 Isolation 9 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 14 . 5" 14. 5" <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No (AI Yes ❑ No I] Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: Q Drain Valve Z Drain Valve El Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) X ❑ Other (Specify in V.) ❑ Other (Specify in V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : Q Pass ❑ Fa ii ❑x Pass ❑ Fail Pass E] Fail ❑ Pass ❑ Faii <br /> V . COMMENTS <br /> Any items marked "Fail " above must be explained in this section. Any additional comments may also be provided here. <br /> 1 <br /> V1 . 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 <br /> if the facility has more components than this form accomm additional copies of this page may be attached. <br />'r <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemationai Code Council <br /> i <br /> E <br /> C <br /> t <br />