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QF= CnEft k sf <br /> P D <br /> Al <br /> UNDERGROUND STORAGE TANK FCB 07 2019 <br /> SPILL CONTAINER TESTING REPORT FORM <br /> Type of Action ❑ Installation Test ❑ Repair Test ® 12vLT H <br /> I . FACILITY INFORMATION ptziDARJUIENT <br /> CERSID : Date : <br /> 10/ 17/2018 <br /> Business Name <br /> Sunwest Chevron <br /> Business Site Address City Zip Code <br /> 2758 W Kettleman Ln Lodi <br /> II , UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Business Name & Address : BZ Service Station Maintenance — 1041 Triangle Ct, West Sacramento CA <br /> Name of UST Service Technician Performing the Test Darnell Smith Phone # 916-371-2380 <br /> Contractor License # 433159 ICC Certification # 8709494 ICC Expiration Date 12/21/ 2019 <br /> Spill Container Testing Training and Certification (List applicable certification . ) <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer (Specify) : <br /> ® Industry Code or Engineering Standard (Specify): PEI 1200 Pg . 11 <br /> Hydrostatic ❑ Engineered Method (Specify) : <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages : <br /> TANK ID : (By tank #, stored product, etc) 87 91 DSL ( 12/27/18 ) <br /> Spill Container Manufacturer : EMCO EMCO EMCO <br /> Method of Cathodic Protection : ® Non - Metallic ® Non - Metallic ® Non - Metallic ❑ Non- Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> Inside Diameter of Spill Container : (Inches) <br /> 15 " 15 15 " <br /> Depth of Spill Container : (Inches) 121/2" 121/2" 121/2" <br /> Does the spill container have a 5 gallon ® Yes E] No ® Yes El NO ® Yes E] No E] Yes E] No <br /> capacity? <br /> Method to Keep Spill Container Empty : ® Drain Value ® Drain Value ® Drain Value E] Drain Value <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> IV . SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail El Pass Pass ❑ <br /> V . COMMENTS <br /> �� additional comments may also be provided here. <br /> Any Items marked Fail" above must be explained in this section . Any <br /> DSL Bucket failed due to bad bucket, will need to replace & retest . <br /> 12/27/ 2018- Replaced DSL Bucket with Elite IV . Retested & all PASSED . <br /> i <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hearby certify that the spill containers were tested in accordance with California Code of Regulations, Title 23, Division 3, Chapter 16, Section <br /> 2637 . 1 and all the information contained herein is accurate . <br /> UST Service Technician Signature <br />