Laserfiche WebLink
UNDERGROUND STORAGE TANK <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 /> 10156819 05/ 14/19 <br /> Business Name (same as Facility Name or DBA-Doing Business As) <br /> Safeway # 2707 <br /> Business Site Address City ZIP Code <br /> 6425 N . Pacific Ave , Stockton 95207 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification .) Phone # <br /> Kristopher Bell (408 ) 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # ICG Certification Expiration Date <br /> 485184 8833000 7/22/20 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 10044933708 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> ® Industry Code or Engineering Standard (Specify) : PEI 1200 <br /> ❑ Engineered Method (Specify) : <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results, 1 <br /> TANK ID : (By tank number, stored product, etc.) 1 Regular 2 Prem 3 Diesel 4 <br /> Spill Container Manufacturer: CNI CNI GNI <br /> Method of Cathodic Protection: ® Non-Metallic m Non-Metallic ® NonWetallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V) <br /> Inside Diameter of Spill Container: (Inches) 13" 13" 13" <br /> Depth of Spill Container: (Inches) 14 .50 14" 14" <br /> Does the spill container have a 5 gallon capacity? © Yes ❑ No © Yes ❑ No © Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ® Drain Valve ® Drain Valve ® Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V) ❑ O [her (Specifyin V) ❑ Other (specify in V.) ❑ Other (Specify in v.) <br /> 1V. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ® Pass El Fail <br /> ® Pass [� Fail ® Pass ❑ Fail ❑ Pass ❑ Faii <br /> V. COMMENTS <br /> Any items marked `Fail" above must be explained in this section . Any additional comments may also be provided here. <br /> Vi . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <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 <br /> If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council <br /> r <br /> I <br />