Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM <br /> Type of Action ❑ Installation Test X Repair Test ❑ 12 Month Test <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180975 6- 19- 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> TOSCO 08671 Stockon 76 <br /> Business Site Address City ZIP Code <br /> 8606 Thornton Stockton 95209 <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 /> Garrett Warren ( 916 ) 991 - 1100 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CSLB#803616 SWRB#06 -1672 8185019 10-2- 19 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW / UST101018 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method <br /> Used : E] Manufacturer Guidelines : <br /> (Specify) <br /> ® Industry Code or Engineering Standard : RP 1200 <br /> (Specify) <br /> ❑ Engineered Method : <br /> (Specify) <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.) 91 89 87 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> X Non-Metallic X Non-Metallic W Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection N Isolation Isolation X Isolation ❑ Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> Inside Diameter of Spill Container: (Inches) 12 " 12 12 " <br /> Depth of Spill Container: (Inches) 12 . 25" 12 . 25 " 12 " <br /> Does the spill container have a 5 gallon I] Yes ❑ No Q Yes ❑ No on Yes ❑ No ❑ Yes ❑ No <br /> capacity? <br /> X Drain Valve (] Drain Valve n Drain Valve ❑ Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results 0 Pass ❑ Fail X Pass ❑ Fail X Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> All items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. <br /> ell <br /> el <br /> I ell <br /> 3 F IA <br /> s !y <br /> ell ee ,,el <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THI _. EVN& 19 <br /> hereby 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 /> � l ; i illi s . := , <br /> if the facility has more componenti�thalFthis form accommodates, additional copies of this page maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council <br />