Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Test ❑ Repair Test M 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10166191 05/26/20 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Hammer 1 -5 Arco <br /> Business Site Address City ZIP Code <br /> 3201 W . Hammer Lane Stockton 95209 <br /> 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> Isaac Anderson (209 ) 532 - 7320 Ext. <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CA 623541 /09- 1749 8146912 06/ 12/20 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW # 100456 exp 05/ 11 /22 <br /> 111 . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : <br /> M Manufacturer Guidelines: (Specify) 1 Hour Hydrostatic Test <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.) 87A Syphon Fill 87B Master Fill 91 Fill <br /> Spill Container Manufacturer: OPW OPW OPW <br /> ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> Method of Cathodic Protection ® Isolation ® Isolation M 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) 10 . 75 10 . 75 10 . 75 <br /> Depth of Spill Container: (Inches) 14 14 14 <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No ® Yes ❑ No M Yes ❑ No ❑ Yes ❑ No <br /> ® Drain Valve M 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 [:] Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> All 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 componentiVithan 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 />