Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM ( Page 1 of 1 ) <br /> Type of Action ❑ Installation Test ❑ Repair Test Q 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180905 8/5/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> JD SINGH as PACIFIC SERVICE STATION <br /> Business Site Address City ZIP Code <br /> 6131 PACIFIC AVE STOCKTON , CA 95207 <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 /> DAVID WINKLER ( 209 ) 744 - 0112 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 0 & 1739 Ex . 3/31 /20 888305MT 1 /29/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 10009853708 Ex . 11 /29/20 <br /> OPW # 104-633 Ex . 3/ 14/2020 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : Nx Manufacturer Guidelines (Specify) : WATER TEST <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify) : <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages 1 <br /> TANK ID : (By tank number, stored product, etc.) 87 91 DSL <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic ❑x Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) <br /> Inside Diameter of Spill Container: (Inches) 12 12 12 <br /> Depth of Spill Container: (Inches) 14 14 14 <br /> Does the spill container have a 5 gallon capacity? El Yes ❑ No ❑x Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: Nx Drain Valve ❑x Drain Valve ❑x Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V) ❑ Other (Specifyin V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ❑x Pass <br /> El ZPass ❑ Fail ❑x Pass ElFail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" above must be explained in this section. Any additional comments dLagbejyovjd0 <br /> Ez: G E i V E urs' <br /> SEP 0 3 2019 <br /> Vi . CERTIFICATION BY UST SERVICE TECHNICIAN COND C 1NRI <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 V "j <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 Coundl <br />