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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 oft ) <br /> Type of Action ❑ Installation Test ❑ Repair Test ;0;1;2;MonthTest <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181407 01 /09/19 <br /> Business Name (Same as Facility Name or DSA-Doing Business As) <br /> Kwik Sery <br /> Business Site Address City ZIP Code <br /> 420 W. Kettleman Ln Lodi 95240 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the iCC Certification.) Phone # <br /> Brian McPheely (408) 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8822062 11 /9/19 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 1014303708 ! 104773 <br /> 111 . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : Manufacturer Guidelines (Specify) : OPW <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify) : <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> TANK ID : (By tank number, stored product, etc.) FNon�Metallic <br /> 2 Diesel 3 Prem E-85 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ® Non-Metallic ® Non- Metallic ❑ Non-Metallic <br /> Isolation El 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 12 12 12 <br /> Depth of Spill Container: (inches) 12 123/4 13 112 121 /2 <br /> Does the spill container have a 5 gallon capacity? [0 Yes E] No [Z Yes ElNo ® Yes E] No ® Yes El 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 /> f <br /> ❑ Other (Specify in V) ❑ Other (Specify in V.J I ❑ Other (Specify in K) El Other (Specify in V.) <br /> I IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ® Pass El ® Pass E] Fail ® Pass ❑ Fait ® Pass El 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 /> Replaced fill caps 87 and Diesel <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 this form accommodates, additional copies of this page may be attached. <br /> CERS = Cat'domia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Counr <br />