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190215 -563 <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM ( Page 1 of 1 ) <br /> Type of Action ❑ Installation Test ❑ Repair Test 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10403278 03/25/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Lodi CA FO Tenn (Intl) <br /> Business Site Address City ZIP Code <br /> 2500 West Turner 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.) JPhone # <br /> Kraig Kinder ( 888) 58 & 8737 <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 /> Franklin Fueling Spill bucket <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : Manufacturer Guidelines (Specify) : OPW <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.) T- 1 /Diesel <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection : ® Non-Metallic ❑ Non-Metallic ❑ Non -Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ 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) l 1 " <br /> Does the spill container have a 5 gallon capacity? ® 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.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : Pass ❑ Fail ❑ Pass El . ail ❑ Pass ❑ Fail ❑ Pass ❑ 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 /> 1 <br /> APR 1 5 2019 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CON DQ&- 1 GifLH &TE$TIN;G ( --AETH <br /> I hereby certify that the spill containers were tested in accordance with California Code of I& ulati6n§",' , Title " 43 , 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 />