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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Pagel of 1) <br /> Type of Action ❑ Installation Test ❑ Repair Test ❑x 12 Month Test <br /> _ I. FACILITY INFORMATION <br /> CERS IDof Spill Container Test <br /> Date <br /> 10180631 6/9/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Quik Stop Market #152 <br /> Business Site AddressCity ZIP Code <br /> 1721 S Cherokee Lane 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 /> Anthony Reyes (916) 372-1885 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 617238 8293772 9/16/2020 <br /> Spill Container Testing Training and Certifications(List applicable certifications) <br /> OPW Tech#103920, Phil-Tite Tech#1003213709 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): <br /> Lake Test <br /> ❑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 Gasoline 91 Gasoline Diesel <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic ❑Non-Metallic <br /> ❑x Isolation ❑x Isolation ❑x 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) 11.5 11.5 11.5 <br /> Depth of Spill Container:(Inches) 12.5 12 12.5 <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑No 0 Yes ❑No 0 Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve x 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: ❑x Pass ❑ Fail 0 Pass El=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 /> 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 A " <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 Counal <br />