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2002 13 -609 <br /> COMPLIANCE ISSUES No Spill Test : Complete <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 (Intl ) <br /> Business Site Address City ZIP Code <br /> 2500 West- Turner Road 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 /> Ruben Becerra (888 ) 588- 8737 <br /> Contractor I 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 /> Ill . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> Industry Code or Engineering Standard (Specify) : PEI - RP 1200 <br /> ❑ Engineered Method (Specify) : <br /> # <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.) T1 l Diesel <br /> Spill Container Manufacturer: 011W <br /> Method of Cathodic Protection : X Non -Metallic ❑ Non-Metallic ❑ Non -Metallic ❑ Non- Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Sperify 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? 0 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 (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specif)l in V. ) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : gj 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 . 0510 : 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 />