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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 NI 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180631 6/13/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Quick Stop Market#152 <br /> Business Site Address City ZIP Code <br /> 1721 S. Cherokee Ln Lodi 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 /> Curtis Carpenter 1 (916) 372-1885 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 617238 8167865 5/13/2020 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW, Phil-Tite RE(-A,--1VED_ <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): JUL <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ENVIRONMENTAL HEALTH <br /> ❑Engineered Method(Specify): DEPAR <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.) 1-87 2-91 3-Diesel <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: x❑Non-Metallic ❑x Non-Metallic 0 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) 13 13 13 <br /> Depth of Spill Container:(Inches) 12.5 12 12.5 <br /> Does the spill container have a 5 gallon capacity? F]Yes ❑ No [R Yes ❑No 0 Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ❑Drain Valve ❑Drain Valve ❑Drain Valve ❑Drain Valve <br /> ❑x Onsite Pump ❑x Onsite Pump ❑x 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: ❑Q Pass ❑ Fail ® Pass ❑ Fail ® 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 /> Replaced the fill cap on the Diesel product before achieving a passing result. <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 Signaturer"= <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 />