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t t <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action Z Installation Test ❑ Repair Test ❑ 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10/31/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Plaza Liquors & Gas <br /> Business Site Address City ZIP Code <br /> 2420 W Turner Rd Lodi 95242 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> Joe Bartholdi (209) 461-6337 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Elite IV 1001331 A-HAZ 2851 11/8/2020 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW 100782 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): Hydrostatic <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 <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection: ❑Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑Other(Specify in V) ❑Other(Specifyin V.) ❑Other(Specifyin V.) ❑Other(Specify in V) <br /> Inside Diameter of Spill Container: (Inches) 1 lit <br /> Depth of Spill Container: (Inches) 13 3/4" <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑ 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(Specifyin V) ❑Other(Specify in V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: N Pass ❑Fail ❑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 <br /> If the facility has more components than is 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 />