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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM <br /> Type of Action ❑ Installation Test ❑ Repair Test ® 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID0 Date : <br /> 6/19/2019 <br /> Business Name <br /> Arco AmPm- Harney <br /> Business Site Address City Zip Code <br /> 255 E Harney 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 Rhome Desbiens Phone # 916-371-2380 <br /> Contractor License # 433159 ICC Certification # 5244364-UT ICC Expiration Date 1/4/2021 <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 <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 #, stored product, etc) 87A 87 B 91 DSL <br /> Spill Container Manufacturer: OPW OPW OPW OPW <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) 11 11" 11" 11" <br /> Depth of Spill Container : (Inches) 14" 14" 14" 14" <br /> Does the spill container have a 5 gallon ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No <br /> capacity? <br /> Method to Keep Spill Container Empty : ® Drain Value ® Drain Value ® Drain Value ® 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 ® Pass ❑ Fail <br /> V. COMMENTS <br /> Any Items marked "Fail" above must be explained in this section. Any additional comments may i edflwyIR <br /> AUh� <br /> TAL <br /> ENVIRONME NJ <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTIN14E #`�N" " <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 /> _ _ L/ <br />