Laserfiche WebLink
UNDERGROUNDSTORAGETANK <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 /> 10165823 7/9/2019 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> 7-ELEVEN #17647, MKT 2368 ( W744 ) <br /> Business Site Address City: Zip : <br /> 1048 W. YOSEMITE AVE @ EL PORTEL MANTECA 95336 <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 /> Jarrod Cooke (800) 800-4633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 5311523-UT 4/3/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> ICC - CA UST Service Technician 5311523-UT 04/03/2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : Manufacturer Guidelines : (Specify) <br /> Industry Code or Engineering Standard : (Specify) PEI RP 1200 <br /> r Engineered Method : (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.) Fill Fill <br /> RULL PULL <br /> Spill Container Manufacturer: OPW OPW <br /> f✓ Non-Mettalic r Non-Mettalic r Non-Mettalic r Non-Mettalic <br /> Method of Cathodic Protection r Isolation r Isolation r Isolation Isolation <br /> F Other r Other r 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) 14 14 <br /> Depth of Spill Container: ( Inches) 12 12 . 5 <br /> Does the spill container have a 5 gallon capacity ? r Yes r No r Yes r No r Yes r No Yes r No <br /> W Drain Valve Drain Valve r Drain Valve r Drain Valve <br /> Method to Keep Spill Container Empty r Onsite Pump Onsite Pump r Onsite Pump r Onsite Pump <br /> r Other r Other r 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 !y PASS r Fail <br /> 'FF%O Fail rPBSS Fail rP1SS Fail <br /> V. COMMENTS <br /> I <br /> i <br /> All items marked failed above must be explained in this section . Any additional comments may also be provided here. <br /> i — <br /> k <br /> F <br /> Vl. CERTIFICATION BY USTSERVICE TECHNICIAN CONDUCTING THIS <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 /> If the facility has more components than this form accommodates , additional copies of this page may be attached . <br /> I CERS=California Environmental Reporting System, ID=Identification , UST=Underground storage tank, ICC=International Code Council <br /> S <br /> 9 <br /> 3 <br />