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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 /> ICERS ID Date of Spill Container Test <br /> 10181231 02/12/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Speedway 4945 <br /> Business Site Address City ZIP Code <br /> 401 W.Kettleman Ln. 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 /> Randy Wilkerson (408)971.2445 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8822029 12/16/21 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> F.F.#1001093708 <br /> OPW#100593 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: JZ Manufacturer Guidelines(Specify): OPW <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> Attach the testing procedures and at/documentation required to determine the results. #of Attached Pages 1 <br /> TANK ID:(By tank number,stored product,etc.) 1 Regular 2 Prem <br /> Spill Container Manufacturer: OPW OPW <br /> Method of Cathodic Protection: Non-Metallic Z 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) 11 11 <br /> Depth of Spill Container:(inches) 13 13 <br /> Does the spill container have a 5 gallon capacity? [Z Yes ❑No 2]Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ®Drain Valve m 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: JZ Pass []Fail 0 Pass ❑Fail ❑Pass []Fall ❑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 />