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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 jDaie-of Spill Container Test <br /> 10181549 9/20/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> BAGLEY - LODI CORP YARD <br /> Business Site Address City ZIP Code <br /> 1331 S . HANE LN LODI , CA 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 /> EDWARD STEARNS 1 (209 ) 744 -0112 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 9/30/20 8883080 - UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 1009893708 Ex . 11 /29/2020 <br /> OPW # 104-635 Ex . 3/ 14/2020 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : 0 Manufacturer Guidelines (Specify) : LAKE TEST <br /> R Industry Code or Engineering Standard (Specify): <br /> ❑ Engineered Method (Specify) : <br /> Attach the testing procedures and all documentation required to determine the results. 7# -of Attached Pages <br /> TANK ID : (By tank number, stored product, etc.) 87 91 [DIESEL <br /> Spill Container Manufacturer: PHIL TITS PHIL TITE CNI <br /> Method of Cathodic Protection: Rx Non-Metallic Z1 Non-Metallic ❑x Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation R Isolation ❑ Isolation <br /> R Other (Specify in v.) ❑ Other (Specify in V.) ❑ Other (Specifyin V.) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 11 11 14 <br /> Depth of Spill Container: (Inches) 12 12 23 <br /> Does the spill container have a 5 gallon capacity? ❑ Yes ❑x No ❑ Yes 0 No I Rx Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: xR Drain Valve 0 Drain Valve ❑x Drain Valve ❑ Drain Valve <br /> R Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> R Other (Specify in V.) ❑ Other (Specify in V.) R Other (Specify in V.) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: Z Pass R Fail Pass R Fail Rx Pass ❑ Fail Tf 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 <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 />