Laserfiche WebLink
If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br />CERS = California Environmental Reporting System, ID = Identification, UST =Underground Storage Tank, ICC = International Code Council <br />UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Test ❑ Repair Test 0 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />10181251 <br />Date of Spill Container Test <br />6/3/2019 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />CANEPA'S CAR WASH <br />Business Site Address City <br />6230 PACIFIC AVE STOCKTON, CA <br />ZIP Code <br />95207 <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 />DAVE WINKLER (209) 744-0112 <br />Contractor I Tank Tester License # <br />08-1739 Ex.3/31 /20 <br />ICC Certification # <br />888305MT <br />ICC Certification Expiration Date <br />1/29/2020 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tite #10009853708 Ex. 11/29/20 <br />OPW #104-633 Ex. 3/14/2020 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />❑X Manufacturer Guidelines (Specify): WATER 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. <br /># of Attached Pages <br />TANK ID: (By tank number, storedproduct, etc.) <br />87 SOUTH <br />91 <br />DSL <br />87 NORTH <br />Spill Container Manufacturer: <br />OPW <br />OPW <br />OPW <br />OPW <br />Method of Cathodic Protection: <br />❑x Non-Metallic <br />❑ Isolation <br />R Other (specify in V.) <br />❑x Non-Metallic <br />❑ Isolation <br />R Other (specify in V) <br />❑X Non-Metallic <br />❑ Isolation <br />❑ Other (Specifyin V) <br />❑x Non-Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />Inside Diameter of Spill Container: (Inches) <br />12 <br />12 <br />12 <br />12 <br />Depth of Spill Container: (Inches) <br />14 <br />15 <br />15 <br />14 <br />Does the spill container have a 5 gallon capacity? <br />R Yes ❑ No <br />❑X Yes ❑ No <br />❑x Yes ❑ No <br />R Yes ❑ No <br />Method to Keep Spill Container Empty: <br />Rx Drain Valve <br />❑ Onsite Pump <br />❑ Other (specify in V.) <br />X Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V) <br />❑X Drain Valve <br />❑ Onsite Pump <br />❑ Other (specify in V.) <br />0 Drain Valve <br />❑ Onsite Pump <br />❑ Other (specify in V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: i] Pass ❑Fail j ❑x Pass ❑ Fail Z Pass El=Fail 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 />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 W <br />If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br />CERS = California Environmental Reporting System, ID = Identification, UST =Underground Storage Tank, ICC = International Code Council <br />