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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 /> 10181325 12/19/19 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Dart Container Corporation <br /> Business Site Address City ZIP Code <br /> 1400 E. Victor Rd. 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 /> Isaac Anderson (209) 532 - 7320 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> CA 623541/09-1749 8146912 06/12/20 <br /> Spill Container Testing Training and Certifications(List applicable certifications.)OPW#100456 RECEIVED <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ����� <br /> ®Manufacturer Guidelines:(Specify) 1 Hour Lake Test <br /> ❑Industry Code or Engineering Standard:(Specify) 1=NUIR(-)NMENTAL HEALTH <br /> ❑Engineered Method:(Specify) DEPARTMENT <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.) Diesel Fill <br /> Spill Container Manufacturer: OPW <br /> ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> Method of Cathodic Protection ® Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) I (Specify in section V) <br /> Inside Diameter of Spill Container:(Inches) 10.75 inches <br /> Depth of Spill Container:(Inches) 14 inches <br /> Does the spill container have a 5 gallon capacity? ®Yes ❑ No ❑Yes ❑ No El Yes [__1 No El Yes El No <br /> ®Drain Valve ❑Drain Valve El Drain Valve El Drain Valve <br /> Method to Keep Spill Container Empty El Onsite Pump ❑Onsite Pump El Onsite Pump [:]Onsite Pump <br /> El Other El Other El Other El 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 ❑ 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 Service Technician Signature <br /> If the facility has more componen6lthan this form accommodates,additional copies of this page may be attached. <br /> CERS=Califomia Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=Intemational Code Council <br />