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UNDERGROUND STORAGE TANK <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 /> 11/15/2018 <br /> Business Name <br /> George Kishida Trucking <br /> Business Site Address City Zip Code <br /> 1725 Ackerman Dr. 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 ICC 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) DSL-1 DSL-2 <br /> Spill Container Manufacturer: <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 /> Depth of Spill Container:(Inches) 17" 131/2" <br /> Does the spill container have a 5 gallon ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> capacity? <br /> Method to Keep Spill Container Empty: ® Drain Value ® 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 RESULTS <br /> Spill Container Test Results: ® Pass [:] Fail I ® Pass E] Fail ❑ Pass ❑ Fail E] 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 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 />