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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 /> 10181447 06/02/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Speedway 4681 <br /> Business Site Address City ZIP Code <br /> 2500 W Lodi 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.) Phone# <br /> Kristopher Bell (408)971-2445 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8833000 7/22/20 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> F.F.#1004933708 <br /> OPW#902968 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines(Specify): <br /> ®Industry Code or Engineering Standard (Specify): PEI 1200 <br /> ❑Engineered Method (Specify): <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages1 <br /> TANK ID: (By tank number,stored product,etc.) 1 Regular 2 Plus 3 Prem 4 Diesel <br /> Spill Container Manufacturer: CNI CNI CNI CNI <br /> Method of Cathodic Protection: 0 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 12 12 12 <br /> Depth of Spill Container: (Inches) 12 1/2 12 1/2 12 1/2 12 1/2 <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: 0 Drain Valve ®Drain Valve ®Drain Valve Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> _j <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: LZI Pass ❑ Fail 0 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 �462� <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=Intemabonal Code Council <br />