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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 Date of Spill Container Test <br /> 10184349 4/23/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Pilot Flying J 617 Lodi <br /> Business Site Address City ZIP Code <br /> 15100 N . Thornton 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 /> Jose Ochoa ( 888 ) 972 -7581 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 804431 AIB HAZ 8004551 - UT 12/27/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW Cert# 100826 <br /> Expiration : 1 - 19-20 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> El Industry code or Engineering standard (specify) : One hour Hydrostatic test - Measuring Tape <br /> ❑ Engineered Method (Specify): <br /> # of Attached Pages <br />' Attach the testing procedures and all documentation required to determine the results. 0 <br /> i <br /> TANK ID : (By tank number, stored product, etc.) Tank#5 - 91 <br /> Spill Container Manufacturer: PhikTlte <br /> Method of Cathodic Protection : ❑x Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specifyin V.) ❑ Other (Specifyin V) ❑ Other (Specify in V) ❑ Other (Specifyin V.) <br /> Inside Diameter of Spill Container: (Inches) 12If <br /> Depth of Spill Container: (Inches) 16If <br /> Does the spill container have a 5 gallon capacity? R Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specifyin 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 El Pass El Fail ❑ Pass ❑ Fail ❑ Pass El 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 />