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 /> 10180519 8/27/20 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Speedway 1486 <br /> Business Site Address City ZIP Code <br /> 13975 E . Hwy 88 Lockeford 95237 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Brian McPheely (408) 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8822062 11 / 1 /2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW # 104773 <br /> Franklin Fueling Site Safety # 1014303708 <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 <br /> Attach the testing procedures and all documentation required to determine the results. Attached Pages1 <br /> TANK ID : (By tank number, stored product, etc.) 1 Regular 2 Prem 3 Diesel <br /> Spill Container Manufacturer: Franklin Franklin Franklin <br /> Method of Cathodic Protection : ® Non-Metallic ® Non-Metallic ® Non-Metallic ❑ 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) 12 12 12 <br /> Depth of Spill Container: (Inches) 15 15 14 <br /> Does the spill container have a 5 gall"capacity? © Yes ❑ No © Yes ❑ No ❑✓ Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empt ® Drain Valve ® Drain Valve ® Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> El Other (Specify in V.) El Other (Specify in V) <br /> El Other (Specify in V.) El Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : Z Pass ❑ Fail�jj 0 Pass ❑ Fail ® Pass ❑ Fail FEI 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 <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 />