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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 ® 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS Ib Date of Spill Container Test <br /> 10184805 10/19/18 <br /> Business Name (Same as facility Name or DBA-Doing Business As) <br /> Rancho San Miguel <br /> Business Site Address City ZIP Code <br /> 610 Cherokee Lane Lodi 95240 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Service Station Systems , Inc. (408) 971 -2445 <br /> Contractor / Tank Tester license # ICC Certification # ICC Certification Expiration Date <br /> 1014303708 8822062 11 /9/ 19 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 1014303708 <br /> 111 . 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.) 1 Regular 2 Prem 3 4 <br /> Spill Container Manufacturer: OPW 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 (Speciryin V.) ❑ Other (Specwin V.) <br /> Inside Diameter of Spill Container: (inches) 12" 12" <br /> Depth of Spill Container: (Inches) 13" 1265" <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 (Specifyin V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: VI 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 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 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 /> I <br />