Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ❑x Installation Test ❑Repair Test ❑ 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 11/25/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Angle Petroleum <br /> Business Site Address City ZIP Code <br /> 7700 Moreland St Stockton 95212 <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 /> Chris Adams (209) 461-6337 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certific tion Expiration Date <br /> 1001331 A-HAZ 1 8230218 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): Hydrostatic <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑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.) 87 91 Diesel <br /> Spill Container Manufacturer: OPW 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) 10.5 10.5 1 10.5 <br /> Depth of Spill Container:(Inches) 16 16 16 <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑No 0 Yes ❑No (]Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ❑x Drain Valve ❑Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify inZ.)j ❑Other(Specify in V.) 0 ❑Other(Specify in V.) ❑Other(Specify in V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑x Pass ❑Fail ❑x Pass ❑Fail I ❑x Pass ❑Fail ❑Pass ❑Fail <br /> V. COMMENTS <br /> Any items marked"Fail'above must be explained in this se tion. Any additional comments may also be provided here. <br /> C60 .,/ hw, ����� �i�,� 1�y�1r <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 /> 14 OIRONMEMMI HEALTH <br /> UST Service Technician Signature —1mv r-1 DFPAPTAAFNT <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 />