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 <br />10181229 <br />_ <br />Date of Spill Container Test <br />01/22/20 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Speedway 4873 <br />Business Site Address <br />35 N. Cherokee Ln. <br />City <br />Lodi <br />ZIP Code <br />95240 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the ICC CertifIcation.) <br />Kristopher Bell <br />Phone # <br />1(408) 971-2445 <br />Contractor / Tank Tester License # <br />485184 <br />ICC Certification* <br />8833000 <br />ICC Certification Expiration Date <br />7/22/20 <br />Spill Container Testing Training and Certifications (list applicable cerlificatlons.) <br />F.F. #1004933708 <br />OPW # 902968 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />Manufacturer Guidelines (Specify): OPW <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the testing procedures and all documentation required to determine the results. <br /># of Attached Pages1 <br />TANK ID: (By tank number, stored product, etc.) <br />1 Regular <br />2 Prem <br />3 Diesel 4 <br />Spill Container Manufacturer: <br />OPW <br />OPW <br />OPW <br />Method of Cathodic Protection: <br />® Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />m Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />la Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify In V.) <br />Inside Diameter of Spill Container: (inches) <br />13" <br />13" <br />13" <br />Depth of Spill Container: (inches) <br />13" <br />13 1/2" <br />13" <br />Does the spill container have a 5 gallon capacity? <br />Fz] Yes ❑ No <br />0 Yes ❑ No <br />® Yes ❑ No <br />❑ Yes ❑ No <br />Method to Keep Spill Container Empty: <br />® Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />m Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V) <br />® Drain Valve <br />❑ Onsite Pump <br />❑Other (Specify in V.) <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: la Pass ❑ Fail la Pass ❑ Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail <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 man this form accommooafes, aaamonar copies or rens page may ue acracneu. <br />CERS = California ErMronmerbl Repor" System, ID = Identification, UST = Underground Storage Tank ICC = International Code Council <br />