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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 ❑x 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180623 3/26/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> COUNTRYSIDE LIQUOR <br /> Business Site Address City ZIP Code <br /> 14971 N HWY 88 LODI 95240 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # <br /> Edward Stearns (209 ) 744 - 0112 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 9/30/20 8883080 - UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 1009893708 Ex . 11 /29/2020 <br /> OPW # 104-635 Ex . 3/ 14/2020 <br /> III . SPILL CONTAINER TESTING INFORM , TI <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify) : LAKE TEST <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify) : ENVII�t� NNI W_. <br /> nrzpApj N6 <br /> Attach the testing procedures and all documentation required to determine the results. Attached Pages <br /> TANK ID : (By tank number, stored product, etc) 87 91 DIESEL <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection : ❑x Non-Metallic ❑x Non-Metallic Z Non-Metallic ❑ Non-Metallic <br /> Z Isolation ❑ Isolation Z Isolation ❑ Isolation <br /> ❑ Other (Specifyin V.) Z Other (Specifyin V) ❑ Other (Specifyin V) ❑ Other (Specifyin V.) <br /> Inside Diameter of Spill Container: (Inches) 11 11 11 <br /> Depth of Spill Container: (Inches) 14 11 12 <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No ❑ Yes ❑x No El Yes ❑ No ❑ Yes ❑ No <br /> I Method to Keep Spill Container Empty: ZDrain Valve 0 Drain Valve Zx Drain Valve ElDrain Valve <br /> Z Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> I <br />€ <br /> El Other (Specifyin V) ❑ Other (Specifyin V) El Other (Specifyin V.) J1 El Other (Specifyin V) <br />( IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : 9 Pass ElFail ZPass ElFail E Pass El Fail El Pass E] Fail <br /> V. COMMENTS <br /> Any items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. <br /> All Buckets pass Lake Test , <br /> 91 Bucket does not hold 5 gallons . <br /> Inspector Zuna on site today . <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 <br /> If the facility has more components 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 />