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 /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181419 04/09/19 <br /> Business Name (Same as FacilityName or DBA-Doing Buslness As.) <br /> San Joaquin County Sheriffs Operations Ctr #1 <br /> Business Site Address City ZIP Code <br /> 7000 N Michael Canlis Blvd French Camp 95231 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service TechnJcian Performing the Test (Pant as shown on the ICC Certification.) Phone # <br /> Eric Molgaard (209 ) 367 - 4000 Ext, <br /> Contractorfrank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 774802 8881020 02/25/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑ Manufacturer Guidelines: (Specify) <br /> H Industry Code or Engineering Standard : (Spec fy) PEI/RP- 1200- 17 <br /> ❑ Engineered Method : (Specify) <br /> Attach the testing procedures and all documentation required to determine the resufts. # of Attached Pages <br /> Tank ID: (By tank number, stored product, etc.) 3701 /GAS 3702/DSL <br /> Spill Container Manufacturer: OPW OPW <br /> ❑ Non-Metallic ❑ NonWMetallic ❑ NonWetallic ❑ Non-Metallic <br /> Method of Cathodic Protection ® Isolation ® Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> (Spectfy in section V.) (Specify In section V.) (Specify in section V.) (Specify In section V.) <br /> 000010 <br /> Inside Diameter of Spill Container: (inches) 12 to <br /> 2" 12" <br /> Depth of Spill Container. (inches) 12 3/4" 12 3/4" <br /> Does the spill container have a 5 gallon capacity? 181 Yes ❑ 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 /> (SpeoW in section V.) (Spectry In section V.) (SpecNy 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 /> r' . <br /> UST Service Technician Signature <br /> DEPARTMENT i <br /> s ' <br /> If the facility has more components thioWos form accommodates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, ID c identification, UST s Unckirgr ound storage tank, ICC = lnI smadonal Code Coundi <br />