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 /> 1 . FACILITY INFORMATION <br /> CERS ID Date JS Container Test <br /> 10181231 2121 /19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Mobil #68152 <br /> Business Site Address City ZIP Code <br /> 401 W. Kettleman Ln . Lodi 95240 <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 /> Michael Briggs (408) 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # E5/30/2019 <br /> Certification Expiration Date <br /> 485184 8033115E <br /> 111.1 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> 1002587081104334 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ® Manufacturer Guidelines (Specify) : OPW <br /> ❑ Industry Code or Engineering Standard (Specify) : <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.) 1 Regular 2 Prem 3 4 <br /> Spill Container Manufacturer: OPW OPW <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) <br /> Depth of Spill Container: (Inches) 13" 13" <br /> Does the spill container have a 5 gallon capacity? © Yes [I No © Yes ❑ No ❑ Yes El No ❑ Yes E] No <br /> Method to Keep Spill Container Empty: ® Drain Valve ® Drain Valve ❑ Drain Valve ❑ Drain Valve <br />[ ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br />� <br /> E] Other (Specify in V) El Other (Specify in V) ❑ Other (Specify in V) ❑ Other (Specify in11 V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> i Spill Container Test Results : ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail FM ass ❑ Fail <br /> j 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 /> I 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 /> j CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank ICC = International Code Canal <br /> I <br />�i' <br />