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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action 0 Installation Test ❑ Repair Test ❑ 12 Month Test <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 6/21 /2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Dart Container <br /> Business Site Address City ZIP Code <br /> 1400 E . Victor Road Lodi 95240 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Pnnt as shown on the ICC Certification.) Phone # <br /> David Rause ( 925 ) 551 -7555 <br /> Contractor I Tank Tester License # ICC Certification # IGC Certification Expiration Date <br /> 220793 8292530 6128/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW Tech Cert. #0108211 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used - ❑x Manufacturer Guidelines (Specify) : Incon TS-STS , Hydrostatic, 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 IDs (By tank number, stored product, etc,) Diesel <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection . 0 Non-Metallic ❑ Non•Metallic ❑ Non-Metallic ❑ Non•Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> _❑�Other.ispecify.in_v. _ ._❑-L11heL(SpaL4jn 'z - - ❑ ZtheL(Specifyinata__ _ ❑Ather (Specifytn . V) <br /> Inside Diameter of Spill Container: (Inches) 12 <br /> Depth of Spill Container (inches) 14 <br /> Does the spill container have a 5 gallon capacity? 91 Yes ❑ No ❑ Yes ❑ No [:] Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑R Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsile 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: 0 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fait <br /> V. COMMENTS <br /> Any items marked "Fail" 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 tested in accordance with California Code of Regulations, Title 23, Division 3 , <br /> Chapter 18, Section 2637. 1 and all the infor tion etained herein is accurate. <br /> UST Service Technician Signature <br /> If the faciUty has more compo ents 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 /> i <br /> i <br />