Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> FTy=peofction ® Installation Test ❑ Repair Test ® 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10182243 11 /26/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> MAIN STREET ARCO AM PM <br /> Business Site Address TCity ZIP Code <br /> 1100 S Main St Manteca 95337 <br /> II, UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Cert cation.) Phone # <br /> Guadalupe Sanchez 1 (925) 470 - 0803 Ext. <br /> Contractorfrank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1005444 5250451 04/05/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> FFS EVR Phase I Systems # 1031393709 Expires : 03/04/2020 OPW # 0163755 Expires : 06/07/2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑ Manufacturer Guidelines: (Specify) <br /> ® Industry Code or Engineering Standard: (Specify) PEI/RP1200- 17 <br /> ❑ Engineered Method: (Specify) <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> Tank ID: (By tank number, stored product, etc.) T2 : 91 <br /> Spill Container Manufacturer. OPW <br /> ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non•Metalifc <br /> Method of Cathodic Protection ® Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ 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) <br /> F1 /2 <br /> Depth of Spill Container. (inches)Does the spill container have a 5 gallon capacity? ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> ® Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ 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 ❑ Fait ❑ Pass ❑ Fafi ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Ali 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, 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 ac mmodates, additional copies of this page may be attached. <br /> CPRS : r`alifnmla Fmn►ro ttiw++nt Rav,rHrw RvaMm In a trianti nAffnn 1 LCT a 1 trviamnv mCi atnrwsP Tank MAI m Intamatinnar rjuia rim mr:ll <br />