COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page t of 1) Type of Action ❑ Installation Test ❑ Repair Test ❑Q 12 Month Test I. FACILITY INFORMATION CERS ID Date of Spill Container Test 10182109 9/23/2019 Business Name (Same as Facility Name or DBA -Doing Business As) MISSION - ABC PETROLEUM Business Site Address City ZIP Code 2375 N. TRACY BLVD TRACY, CA 95376 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 I Tank Tester License # ICC Certification # ICC Certification Expiration Date 04-1676 Ex. 3/31/19 8883064 -UT 6/1/2019 Spill Container Testing Training and Certifications (List applicable certifications.) Franklin Fueling - EBW & Phil Tite #10009843708 Ex. 11/29/2020 OPW #104-632 Ex. 3/14/2020 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): ❑ Engineered Method (Specify): Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK ID: (By tank number, stored product, etc.) Spill Container Manufacturer: Method of Cathodic Protection: Inside Diameter of Spill Container: (Inches) Depth of Spill Container: (Inches) Does the spill container have a 5 gallon cal Method to Keep Spill Container Empty: Spill Container Test Results: 87 OCT O P W ❑x Non -Metallic ❑ Isolation ❑ Other (Specify in V.) 11 1/2 12 1/2 0 Yes ❑ No 91 OCT O P W ❑x Non -Metallic ❑ Isolation ❑ Other (Specify in V.) 11 1/2 11 1/2 R Yes ❑ No Zx Drain Valve ❑x Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Other (Specify in V) ❑ Other (Specify in V.) IV. SUMMARY OF TESTING RESULTS ❑ ❑x Pass Fail ❑X Pass [_1Fail IF DIESEL #2 O P W ❑x Non -Metallic ❑ Isolation ❑ Other (Specify in V.) 11 1/2 13 - El Yes ❑ No Zx Drain Valve ❑ Onsite Pump ❑ Other (Specify in V) WASTE OIL O P W Zx Non -Metallic ❑ Isolation ❑ Other (Specify in V.) 11 1/2 13 1/2 N Yes ❑ No Zx Drain Valve ❑ Onsite Pump ❑ Other (Specify in V) ❑x Pass ❑ Fail 11 ❑x Pass ❑ Fail V. COMMENTS Any items marked "Fail' above must be explained in this section. Any additional comments may also be provided here. WASTE OIL NOT USED. TESTED AND PASSED. 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 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 = International Code Council