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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 /> 10/28/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Plaza Liquors & Gas <br /> Business Site Address City ZIP Code <br /> 2420 W Turner Rd Lodi 95242 <br /> lie UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # <br /> Michal Kennard (209 ) 461 -6337 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1001331 A-HAZ 5254811 6/19/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW EVR VST # 104790 EXP 5/23/2021 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify): 1 HR Hydrostatic 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.) 91 <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection: ❑ Non-Metallic ❑ Non-Metallic ❑ Non4etallic ❑ Non-Metallic <br /> ❑x Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specifyin V) <br /> Inside Diameter of Spill Container: (inches) 11 . 5 <br /> Depth of Spill Container: (Inches) 137/8 <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: [E] Drain Valve ❑ Drain Valve ❑ 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 : 21 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ 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 /> I <br /> r <br /> i <br /> VIS 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 cont ' e n is accurate. <br /> UST Service Technician Signature <br /> If the facility has more cofnp6nents than this form accommodates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />