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190717-601 <br /> COMPLIANCE ISSUES : No ' Spill Test: Complete <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action F1 installation Test ❑ Repair Test 12 Month Test <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181479 08/21 / 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Mid City Ca FO Regen <br /> Business Site Address City ZIP Code <br /> 13850 Devries Road Lodi 95242 <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 /> Kraig Kinder (888) 5884737 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 703190 8296393 12/07/20 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 111 . SPILL 'CONTAINER TESTING INFORMATION <br /> Test Method Used: D4 Manufacturer Guidelines (Specify): PEI-RP420042 <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) Tank#313 <br /> Spill Container Manufacturer: EBW <br /> Method of Cathodic Protection : �$( Non-Metallic ❑ Non -Metallic ❑ Non -Metallic ❑ NonWetallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) I ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (inches) 12 " <br /> Depth of Spill Container: (Inches) 13 " <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: ® Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) 11 ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : H Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ FaH 'El <br /> Pass Fail . <br /> V. COMMENTSFYI <br /> Any items marked `Fail" above must be explained in this section. An additional comments may �~� <br /> Y y o be provided here. <br /> GJi 4. t `°4 k <br /> VI . 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 Digitally signed by Kraig Kinder <br /> Kraig Kinder Date: 2019 .08.21 11 : 26 :05 =07'00' <br /> If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />