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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Test ❑Repair Test ❑x 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10184349 4/15/2020 <br /> Business Name(Sarre as Facility Name or DBA-Doing Business As) <br /> Pilot Flying J 617 Lodi <br /> Business Site Address City ZIP Code <br /> 15100 N. Thornton 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 /> Jose Ochoa (888) 972-7581 <br /> Contractor:Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 804431 A,B HAZ 8004551-UT 10/28/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW Cert# 100826 <br /> Expiration: 12-28-2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines(Specify). <br /> p Industry code or Engineering Standard (specify): Tape Measurer- Stop Watch - One hour hydrostatic test. <br /> ❑Engineered Method(Specify): <br /> #of <br /> Attach the testing procedures and all documentation required to determine the results. Attached Pages 2 <br /> TANK to: (By tank number, stored product,etc.) T-5 91 <br /> Spill Container Manufacturer: Phil-Tite <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(Specify in V.) ❑Other(Specifyin V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 1 21f <br /> Depth of Spill Container:(Inches) 1611 <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 inV.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specrfy in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: Z Pass ❑ F iif ❑ Pass ❑ Fail �IF ❑ 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 �y <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 />