COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Test ❑ Repair Test ❑x 12 Month Test I . FACILITY INFORMATION CERS ID Date of Spill Container Test 10180905 8/ 19/2020 Business Name (Same as Facility Name or DBA-Doing Business As) SYNERGY - PACIFIC SERVICE STATION Business Site Address TSTOCKTOK ity ZIP Code 6131 PACIFIC AVE CA 95207 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # ZANE NIMMO ( 209 ) 744 - 0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 04- 1676 Ex . 3/31 /22 8883064 - UT 6/ 1 /2021 Spill Container Testing Training and Certifications (List applicable certifications.) Franklin Fueling - EBW & Phil Tite # 10009843708 Ex . 11 /29/2020 OPW # 104- 632 Ex . 3/ 15/2022 III . SPILL CONTAINER TESTING INFORMATION Test Method Used : ❑x Manufacturer Guidelines (Specify) : O P W PHASE I LAKE TESTING ❑ Industry Code or Engineering Standard (Specify) : Z Engineered Method (Specify) : Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, storedproduct, etc.) 87 OCTANE 91 OCTANE DIESEL # 2 Spill Container Manufacturer: O P W O P W O P W Method of Cathodic Protection : ❑x Non-Metallic ❑x Non-Metallic ❑x Non-Metallic ❑ Non-Metallic ❑ Isolation ❑ Isolation Z Isolation ❑ Isolation ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specifyin V) ❑ Other (Specify in V.) Inside Diameter of Spill Container: (Inches) 11 1 /2 11 1 /2 11 1 /2 Depth of Spill Container: (Inches) 12 1 /2 11 1 /2 11 1 /2 Does the spill container have a 5 gallon capacity? ❑x Yes Z No ❑ Yes R No ❑ Yes ❑x No ❑ Yes ❑ No Method to Keep Spill Container Empty: Zx Drain Valve 0 Drain Valve ❑x Drain Valve ❑ Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump Z Onsite Pump Z Other (Specify in V.) ❑ Other (specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : ❑x Pass ❑ Fail ❑x Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass Z Fail V. COMMENTS fmnjV IL Any items marked "Fail" above must be explained in this section . Any additional comments Pf f ;Tb Y r vie ff �M BOTH 91 AND DIESEL ABOUT 8 OZ . SHORT OF 5 GALLONS , k3 ft SEP 1 1 2020 ENVIRONMENTAL HEALTH DFPARTI\AFNT VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations , Title 23 , Division 3 , Chapter 16, Section 2637 . 1 and all the information contained herein is accurate. UST Service Technician Signature if the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council