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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action E]Installation Test ❑Repair Test 91;12Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181613 1/7/19 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> VDP - RIPON CFN <br /> Business Site Address Ciry 21P Code <br /> 816 S FRONTAGE RD RIPON, CA 96366 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the IGC Certification.) Phone# <br /> EDWARD STEARNS (209) 744-0112 <br /> Contractor/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 /> ILI. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: i]Manufacturer Guidelines(Specify): LAKE TEST <br /> E] 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.) 87 91 DSL <br /> Spill Container Manufacturer. PHIL TITE PHIL TITE PHIL TITE <br /> Method of Cathodic Protection: M Non-Metallic 2]Non-Metallic 21 Non-Metallic E]Non-Metallic <br /> ❑Isolation El Isolation ❑Isolation I]Isolation <br /> E)Other(Specify in V) []Other(Specify in V.) El Other(Specify in V.) E]Other(Specify in V) <br /> Inside Diameter of Spill Container: (Inches) 11 11 11 <br /> Depth of Spill Container.(Inches) 13 13 12 <br /> Does the spill container have a 5 gallon capacity? Mx Yes El No [j]Yes E]No []Yes it No ❑Yes <br /> ❑No <br /> Method to Keep Spill Container Empty: [x Drain Valve R1 Drain Valve . I[Drain Valve . E].Drain Valve <br /> ❑Onsite Pump E]Onsite Pump ❑Onsite Pump El Onsite Pump <br /> ❑Other(Specify in V) ❑Other(Specify in V.) ❑Other(Specify in V) E]Other(Specify in V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: x[,l Pass 0 Fail 1 21 Pass ❑Fail I Ea Pass Q Fail ❑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 /> DIESEL SPILL BUCKET DOES NOT HOLD 5 GALLONS.FAILED. <br /> Repair and retest by bonlee 8/19/19-with Inspector Woldearegay present <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 Ern*urrnental Reporting System,D= UST=Underground Storage Tank,ICC=hmuttlonal Code Council <br />