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COMPLIANCE INFO_2020
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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D
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DR MARTIN LUTHER KING JR
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2300 - Underground Storage Tank Program
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PR0231058
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COMPLIANCE INFO_2020
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Entry Properties
Last modified
12/14/2020 11:56:16 AM
Creation date
5/15/2020 3:13:05 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2020
RECORD_ID
PR0231058
PE
2361
FACILITY_ID
FA0003738
FACILITY_NAME
CHARTER WAY SHELL*
STREET_NUMBER
620
Direction
W
STREET_NAME
DR MARTIN LUTHER KING JR
STREET_TYPE
BLVD
City
Stockton
Zip
95206
APN
16504007
CURRENT_STATUS
01
SITE_LOCATION
620 W DR MARTIN LUTHER KING JR BLVD
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
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SJGOV\kblackwell
Tags
EHD - Public
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UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM ( Page 1 of 6) <br /> Type of Action ❑ Installation Test ❑ Repair Test ❑ Six Month Test n 36 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 10181363 3/20/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Charter Way Shell <br /> Business Site Address city ZIP Code <br /> 620 West Charter Way Stockton 95206 <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 /> Benjamin Duncan ( 707 ) 621 -0378 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Tank Tester License #90- 1120 5246802- UT 3/21 /2021 <br /> III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID : (Bytanknumber, storedproduct, etc.) A T- 1 -91 B T-2-87 C T-3- Diesel D <br /> Tank Containment <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Product Piping Containment <br /> Tightness Test Result O Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Vent Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Turbine / Product Piping Sump <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Fill Riser Sump <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> VENT / TRANSITION SUMP ID : a b C d <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID : 1 1 &2 2 3&4 3 5&6 4 7&8 <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA <br /> UDC ID : 5 9& 10 6 11 & 12 7 8 <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA I ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID : 9 10 11 12 <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> All items marked "Fail' or "NA " must be explained in their respective "COMMENTS" section. <br /> IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the secondary containment was tested in accordance with California Code of Regulations , Title 23, Division <br /> 3 , Chapter 16, Section 2637 and all the informations contained herein is accurate. <br /> UST Service Technician Signature ti�� n/i?r �` a.lJ�ncarri� <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, NA = Not Applicable, UDC = Under- <br /> Dispenser Containment <br />
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