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06 / 28 / 2019 19 : 29 8387674 Eiv1ILS PAGE 27 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page I of 1 ) <br /> FTyoeofn <br /> El Installation Test C� Repair Test El 12 Month T¢si <br /> I . FACILITY INFORMATION <br /> Date of spill container Test <br /> CERS ID 5/29/2019 <br /> 10180567 <br /> Business loo4zme (Same es Facility Neme or DBA•Doing Business As) <br /> EMIUS LiQUOR AND SPORE' S SHOP city zP code I <br /> I✓usiness Site Address 95320 <br /> 1405 CALIFORNIA STREET ESCALON , CA <br /> It . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Teat (Print as shown on the ICC Certification.) Phone # <br /> FELIX RAMIREZ (209 ) 744 -0112 <br /> :1Contractor I Tank Tester License # ICC Cel it; # ICC Certiflc3tion Expiration Date <br /> 08- 1740 5 -31 -20 8883072-UT 11 /9/2020 <br /> Mo <br /> Spill Container Testing Training and Oertificatlons (List applicable certifi'catlons.) <br /> Franklin Fueling - EBW & Phil Tite # 1009883708 11 /29/20 -- <br /> OPW # 104634 3- 14 -20 d —� 11 <br /> 111. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : R Manufacturer Guidelines (Specify) : LAKE TEST <br /> n Industry Code or Engineering Standard (Specify): <br /> ❑ Engineered Method (Specify) : <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> TANK ID : (By tank number, stored product, eta) 8 7 91 Dl ES ELMoo <br /> Spill Container Manufacturer: <br /> OPW OPW OP v <br /> Method of Cathodic Protection; x❑ Non�Melallic i] Non-Metallic i] Non-Metallic ❑ Non-Metallic <br /> ❑ isolation I] Isolation [] Isolation ❑ Isolation <br /> Q Other (specNyin V.) L1 Other (Spectryin VJ ❑ Other (Speclryin V.) I�] Other (Specrryin v.) <br /> Moo <br /> Inside Diameter of Spill ContaineC (inches) 11 1 1 — jNo Depth of Spill Container: (1nChOS) 14 14 14 <br /> X No x Yes ❑ No ❑ Yes <br /> Does the spill container have a 5 gallon capacity? p Yes (� No ❑ Yes ❑ ❑ Drain Valve <br /> x Drain Valve Drain Valve ❑ <br /> Method to Keep Spill Container Empty: Q Drain Valve Q <br /> �] Onsite Pump ❑ Onsite Pump C1 Onsite Pump ❑ Ort5ite PUmp <br /> ❑ Other (Specify In V.) ❑ Other (Specify in v.) [ ] Other (Specify in v.) ❑ 011ier (SPecify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: <br /> x❑ Pass ❑ Fail M I Z Pass ❑ Fait ❑x Pass p Fait ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items maed "rail" abve m <br /> oust be explained in this section. Any additional comments may also be provided here. <br /> rk <br /> Vol . CERTIFICATION 13Y UST SERVICE TECHNICIAN CONDUCTING THIS TESTING _ <br /> rdance with California Code of Regulations , Title 23 , Division 3 , <br /> ( hereby certify that the spill containers were tested in acco <br /> Chapter 16 , Section 2637 .1 and all the information contained herein is accurate . <br /> UST Se vita Cechnician Signature )f .; .. • ;,roo <br /> � - ,� <br /> if the facility has more components than this form accommodates, additional copies of this page may be attached, <br /> v CEPS = California Environmo Repo" SYjern, ID = IdctMcation, U51' = Undergrotmd Storage "tank, ICC = International Code Council <br /> Received Time Jun , 28 . 2019 7 . 27PM No , 5223 <br />