Laserfiche WebLink
UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Test ❑ Repair Test ❑X 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />10182335 <br />Date of Spill Container Test <br />4/22/2020 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />TRACY TRUCK STOP <br />Business Site Address <br />3940 N TRACY BLVD <br />City <br />TRACY <br />ZIP Code <br />95304 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the /CC Certification.) <br />David Winkler <br />Phone # <br />(209) 744-0112 <br />Contractor / Tank Tester License # <br />08-1739 Ex.3/31 /20 <br />ICC Certification # <br />8883059 -UT <br />ICC Certification Expiration Date <br />1/27/2022 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tite #10009853708 Ex. 11/29/20 <br />OPW #104-633 Ex. 3/13/2022 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />❑x Manufacturer Guidelines (Specify): WATER TEST <br />❑ Industry Code or Engineering Standard (Specify): <br />r <br />❑ Engineered Method (Specify): <br />Attach the testing procedures and all documentation required to determine the results. <br /># of Attached Pages <br />TANK ID: (By tank number, stored product, etc.) <br />87 <br />91 <br />DSL <br />DSL 2 <br />Spill Container Manufacturer: <br />opw <br />opw <br />opw <br />OPW <br />Method of Cathodic Protection: <br />❑X Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in v.) <br />❑X Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V) <br />❑X Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V) <br />❑X Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />Inside Diameter of Spill Container: (Inches) <br />12 <br />12 <br />12 <br />12 <br />Depth of Spill Container: (Inches) <br />14 <br />14 <br />14 <br />14 <br />Does the spill container have a 5 gallon capacity? <br />El Yes ❑ No <br />50 Yes ❑ No <br />0 Yes ❑ No <br />R Yes ❑ No <br />Method to Keep Spill Container Empty: <br />❑x Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />(] Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑X Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V) <br />❑x Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: <br />❑X Pass ❑ Fail <br />❑X Pass ❑ Fail 11 <br />❑X Pass ❑ Fail ❑x 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 />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 ^ t <br />If the facility has more components than this form accommodates, additional copies of this page may be attached. <br />CERS = California Environmental Reporting System, ID = Identification, UST= Underground Storage Tank, ICC = International Code Council <br />