Laserfiche WebLink
UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM(Page 1 of 1) <br /> Type of Action r Installation Test r Repair Test F%0_ 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10181341 11/12/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> CHEVRON#99840(N31) <br /> Business Site Address City: Zip: <br /> 4344 E WATERLOO RD @ 99 STOCKTON 95215 <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 /> Jarrod Cooke (800)800-4633 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Class A General Engineering 743160 5311523-UT 4/3/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> ICC-CA UST Service Technician 5311523-UT 04/03/2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: r Manufacturer Guidelines: (Specify) <br /> W Industry Code or Engineering Standard: (Specify) PEI RP 1200 <br /> r Engineered Method: (Specify) <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> Tank ID: (By tank number, stored product, etc.) Fill T1 Fill T2 <br /> SUPREME REG UNLEAD <br /> Spill Container Manufacturer: Franklin/EBW Franklin/EBW <br /> P Non-Metallic r Non-Metallic r Non-Metallic r Non-Metallic <br /> Method of Cathodic Protection r Isolation r Isolation r Isolation r Isolation <br /> F Other r Other r Other r Other <br /> Specify in section V) (Specify in section V) (Specify in section V) (Specify in section V) <br /> Inside Diameter of Spill Container: (Inches) 11.5 11.5 <br /> Depth of Spill Container: (Inches) 14.25 14.25 <br /> Does the spill container have a 5 gallon capacity? r Yes r No W Yes r No r Yes r No r Yes r No <br /> W Drain Valve r Drain Valve r Drain Valve r Drain Valve <br /> Method to Keep Spill Container Empty r Onsite Pump r Onsite Pump r Onsite Pump r Onsite Pump <br /> F Other r Other r Other r Other <br /> (Specify in section V) (Specify in section V) (Specify in section V) (Specify in section V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results Pass r Fail I 1"PASS r Fail rPass r Fail rPass r Fail <br /> V. COMMENTS <br /> All items marked failed above must be explained in this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> hereby certify that the spill containers were tested in accordance with California Code of Regulations,title 23,division 3,chapter 16,section <br /> 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 />