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200714-616 <br /> COMPLIANCE ISSUES: No 19 Spill Test: Complete <br /> UNDERGROUNDSTORAGETANK <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 I D Date of Spill Container Test <br /> 10181479 08/18/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Mid City Ca FO Regen <br /> Business Site Address City ZIP Code <br /> 13850 Devries 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 /> Kraig Kinder (888)588-8737 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 703190 8296393 12/07/20 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> EBW <br /> 111. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines(Specify): <br /> Industry Code or Engineering Standard (Specify): PEI-RP-1200-12 <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.) 'Tank#313 <br /> Spill Container Manufacturer: EBW <br /> Method of Cathodic Protection: ®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) I " <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(Specify in 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 11 ❑ 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 Kraig Kinder <br /> Kraig Kinder Date: 2020.08.18 09:37:57-07'00' <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 />