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UNDERGROUND STORAGE TAN <br /> SPILL CONTAINER TESTING REPORT FORM <br /> Type of Action ❑ Installation Test ❑ Repair Test ® 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERSID : Date : <br /> 11/8/ 2018 <br /> Business Name <br /> Arco AmPm- Victor Rd <br /> Business Site Address City Zip Code <br /> 880 E Victor Rd Lodi <br /> II , UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Business Name & Address : BZ Service Station Maintenance — 1041 Triangle Ct, West Sacramento CA <br /> Name of UST Service Technician Performing the Test Rhome Desbiens I Phone # 916-371-2380 <br /> Contractor License # 433159 ICC Certification # 5244364 IC Expiration Date 1/ 5/2019 <br /> Spill Container Testing Training and Certification (List applicable certification . ) <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer (Specify): <br /> ® Industry Code or Engineering Standard (Specify): <br /> Hydrostatic ❑ Engineered Method (Specify): <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages : <br /> TANK ID : (By tank ##, stored product, etc) 87 91 DSL <br /> Spill Container Manufacturer : OPW OPW OPW <br /> Method of Cathodic Protection : ® Non - Metallic ® Non- Metallic ® Non- Metallic ❑ Non - Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> Inside Diameter of Spill Container : (Inches) <br /> 11 " 11" ii " <br /> Depth of Spill Container : (Inches) 13 " 131/2 " 131/2 <br /> Does the spill container have a 5 gallon ® Yes ❑ No ® Yes ❑ N ® Yes ❑ No El Yes El No <br /> capacity ? <br /> Method to Keep Spill Container Empty : ® Drain Value E3 Drain Value ® Drain Value Drain Value <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> IV , SUMMARY OF TESTING RESULT <br /> Spill Container Test Results : ® Pass ❑ Fall ® Pass ❑ Fa I ® Pass ❑ Fail ❑ Pass E] Fail <br /> V . COMMENTS <br /> Any Items marked "Fail" above must be explained in this section . Any additional comments may ols o be provided here. <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> hearby 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 />