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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM <br /> Type of Action ❑ Installation Test ❑ Repair Test Q 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181885 01/14/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> VALLEY PACIFIC LODI PLANT&CARDLOCK <br /> Business Site Address City ZIP Code <br /> 931 E Victor Ave. 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 /> Garrett Warren (916) 991 - 1100 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> CSLB#803616 8185019 9-20-2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW EVR 101018 exp. 6-5-2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method <br /> Used: El Manufacturer Guidelines: <br /> (Specify) <br /> ® Industry Code or Engineering Standard: RP 1200 <br /> (Specify) <br /> ❑ Engineered Method: <br /> (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.) T6: 87 UNL T7: 87 UNL <br /> Spill Container Manufacturer: OPW OPW <br /> 0 Non-Metallic N Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection IN Isolation 0 Isolation ❑ Isolation ❑Isolation <br /> ❑Other ❑Other ❑ Other ❑Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container: (Inches) <br /> Depth of Spill Container:(Inches) 11.25° 11.50" <br /> Does the spill container have a 5 gallon El Yes ❑ No [j]Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No <br /> capacity? <br /> ❑ Drain Valve Drain Valve ❑ Drain Valve ❑Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑ Other ❑Other ❑Other ❑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 X Pass ❑ Fail 11 N 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 /> 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 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 />