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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Action ElInstallation Test ❑ Repair Test ❑x 12 Month Test I . FACILITY INFORMATION CERS IDDate of Spill Container Test 10180633 9/ 16/2020 Business Name (Same as Facility Name or DBA-Doing Business As) SHORT STOP FOOD MART Business Site Address City ZIP Code 20A WEST TURNER ROAD LODI , CA 95240 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the /CC Certification.) Phone # FELIX RAMIREZ (209 ) 744 - 0112 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 08 - 1740 5 - 31 -23 8883072 - UT 11 /9/2020 Spill Container Testing Training and Certifications (List applicable certifications.) Franklin Fueling - EBW & Phil Tite # 1009883708 11 /29/20 OPW # 104634 3 - 14-22 III . SPILL CONTAINER TESTING INFORMATION Test Method Used : ❑ Manufacturer Guidelines (Specify) : Z Industry Code or Engineering Standard (Specify) : LAKE TEST / PEI ❑ Engineered Method (Specify) : Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK I D : (By tank number, stored product, etc.) 87 91 DIESEL Spill Container Manufacturer: EBW EBW OPW Method of Cathodic Protection : ❑x Non-Metallic ❑x Non-Metallic Z Non-Metallic ❑ Non-Metallic ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V) ❑ Other (Specify in V.) Inside Diameter of Spill Container: (Inches) 11 11 11 Depth of Spill Container: (Inches) 16 16 15 Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No 0 Yes ❑ No Z Yes ❑ No ❑ Yes ❑ No Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ❑x Drain Valve ❑ Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Other (Specifyin V.) ❑ Other (Specifyin V) ❑ Other (Specifyin V.) ❑ Other (Specifyin V) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : IF ❑x Pass ❑ Fail ❑x Pass ❑ Fail ❑x Pass El L1 Pass El Fail V. COMMENTS Any items marked "Fail' above must be explained in this section. Any additional comments may also be provided here. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations , Title 23, Division 3, Chapter 16, Section 2637 . 1 and all the information contained herein is accurate . UST Service Technician Signature r, r - If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council