Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Pago t of 1) <br /> Type of Action ❑Installation Test <br /> ❑Repair Test ❑x 12 Month Test <br /> I. FACILITY INFORMATION <br /> F <br /> ID Date of Sp II Conlarner Test <br /> 1/22/2019 <br /> ess Name(Same as Facility Name or DBA-Doing Business As)o 6080 <br /> Business Site Address CityZIP Code <br /> 85 E Louise Ave Lathrop 95330 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Techncian P <br /> ierforming the Test(Print as shown on the Icc Certification) Phone# <br /> David Rouse (925) 551-7555 <br /> Contractor I Tank Tester License# ICC Cerhficalion# ICC Certification Expiration Dale <br /> 220793 8292530 6/28/2020 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used ❑Manufacturer Guidelines(Specify) <br /> x❑Industry Cade or Eng-veering Standard(Specify) <br /> hiydrostaic, Tape Measure <br /> ❑Engineered Method(Specify) <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> TANK ID:(By lank number,storod producl,etc) T1 Unleaded (A) T1 Unleaded (B) T2 PremiumFIsolation <br /> el <br /> Spill Container Manufacturer OPW-Product OPW-Product OPW-Productuct <br /> Method of Cathodic Protection ❑x Non-Metallic ❑x Non-Metallic ❑x Non-Metallic <br /> ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(Specify in v) ❑Other(Specify(I;v) ❑Other(Specify in v) ❑Other(Specify in v) <br /> Inside Diameter of Spill Container (Inches) 12" <br /> 1211 1211 1211 <br /> Depth of Spill Container (Inches) 14" 14" 14" 14" <br /> Does the sp.11 container have a 5 gallon capac ty'> 2)Yes ❑No []Yes ❑No Yes ❑No Yes ❑No <br /> Method to Keep Spill Container Empty 0 Drain Valve Drain Valvex❑Drain Valve ❑x Dra=n Valve <br /> ❑Onsite Pump ❑Onsile Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in v) ❑Other(Specify in v) ❑Other(Specify in v) ❑Other(Spe cdy in v; <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ❑x Pass ❑Fail ❑x Pass ❑Fail Q 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 /> 1 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 con fined ein is accurate. <br /> UST Service Technician S gnature <br /> If file facility has more components than s form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,10=Identification.UST=underground Storage Tank.ICC=International Code Council <br />