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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 ID Date of Spill Container Test <br /> 0 / 5�7/ j47g 2-1-19 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Valley Pacific Petroleum <br /> Business Site Address <br /> City ZIP Code <br /> 930 = ,�- l/c��.z Lodi 95240 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the/CC Certification) Phone# <br /> Torstein Armour (707)437-6668 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 498721 78202044 4/17/19 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW VR-102 EVR UST Installer#0162927 exp. 7/11/2020 <br /> Test Method Used: III. SPILL CONTAINER TESTING INFORMATION <br /> ❑Manufacturer Guidelines:(Specify) <br /> i&lDdustry Code or Engineering Standard:(Specify) lZ <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.) T7 87 LIN <br /> Spill Container Manufacturer: OPT/ <br /> ®Non-Metallic Q Non-Metallic ❑Non-Metallic <br /> ❑Non-Metallic <br /> Method of Cathodic Protection ❑Isolation ❑Isolation ❑ Isolation ❑Isolation <br /> ❑Other ❑Other ❑Other <br /> (Specify in section V.) (Specify in section V ❑Other <br /> (Specify in section V) (Specify in section V.) <br /> Inside Diameter of Spill Container:(inches) <br /> Depth of Spill Container:(Inches) 13 <br /> Does the spill container have a 5 gallon capacity? ®Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> ®Drain Valve ❑Drain Valve Cl Drain Valve <br /> ❑Drain Valve <br /> Method to Keep Spill Container Empty ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump El Onsite Pump <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ®Pass ❑Fail 1 ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail <br /> V. COMMENTS <br /> All 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,chapter 16,section <br /> 2637.1 and all the information contained herein is accurate. <br /> UST Se n igpna <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Callfomia Environmental Reporting System,ID=identification,LIST=Underground storage tank,ICC=h6arr>ationai Code Council <br />