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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 0 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180603 2/22 / 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> RUPI - BILLS 76 <br /> Business Site Address City ZIP Code <br /> 633 VICTOR RD LODI , CA 95240 <br /> 11 . 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 (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.) r k' i <br /> VIM <br /> Franklin Fueling - EBW & Phil Tite # 1009893708 Ex . 11 /29/2020 R E N <br /> OPW # 104-635 Ex . 3/ 14/2020 <br /> III . SPILL CONTAINER TESTING INFORMATION F i- B a O <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify): lake test <br /> ❑ Industry Code or Engineering Standard (Specify) : ENVIRONMENTAL HEACI <br /> ,-Pi a <br /> ❑ Engineered Method (Specify) : <br /> Attach the testing procedures and all documentation required to determine the results. 7iof Attached Pages <br /> TANK ID : (By tank number, stored product etc.) 87 89 91 <br /> Spill Container Manufacturer: OPW opw opw <br /> Method of Cathodic Protection : ❑x 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) 11 11 11 <br /> Depth of Spill Container: (Inches) 13 13 13 <br /> Does the spill container have a 5 gallon capacity? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> I <br />� Method to Keep Spill Container Empty: Z Drain Valve 9 Drain Valve ❑D Drain Valve EJ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specifyin V.) ❑ Other (Specify in V. <br /> 4 IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : Pass E] Fail 9 Pass El Fail X Pass El 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 /> 1 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 = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council <br />