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COMPLIANCE ISSUES: No = Spill Test: Complete 200213-609 <br /> 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 /> 10403278 03/05/20 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Lodi CA FO Term(Inti) <br /> Business Site Address City ZIP Code <br /> 2500 West Turner Road 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 /> Ruben Becerra 1 (888)588-8737 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 703190 5302139 02/05/21 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> opw <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines (Specify): <br /> N Industry Code or Engineering Standard (Specify): PEI-RP 1200 <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.) T-1 Diesel <br /> Spill Container Manufacturer: OPW <br /> Method of Cathodic Protection: DK 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" <br /> Depth of Spill Container: (Inches) 13" <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: ®Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specifyin V.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ® 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 Digitally signed by Ruben Becerra <br /> Ruben Becerra Date:2020.03.05 10:23:07-08'00' <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 Council <br />