Laserfiche WebLink
i <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action M Installation Test ❑ Repair Test ❑ 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 9/5/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Chevron <br /> Business Site Address City ZIP Code <br /> 9015 Walnut Grove Rd Thornton 195686 <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 Certification Expiration Date <br /> 8230218 ,�. .�i/,19,/,2Q1:9 ,; ;s r; <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> FFS EVR Phase I VR101 Cert# 1014863710 ' I` <br /> III . SPILL CONTAINER TESTING INFORMATION ? �; <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify): Hydrostatic <br /> ❑ Industry Code or Engineering Standard (Specify): <br /> 0, EPAPIMENT <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.) 91 Diesel <br /> Spill Container Manufacturer: PhikTite PhikTite <br /> Method of Cathodic Protection: 0 Non-Metallic ❑x 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) 12 12 " <br /> Depth of Spill Container: (inches) 16 . 25" 16 . 5" <br /> Does the spill container have a 5 gallon capacity? El Yes ❑ No [j] Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Z x Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> to Kee Sill Container Empty: Drain Valve ❑ <br /> Method ❑ <br /> P P <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ 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 ❑ Pass ❑ 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 /> Test 91 and diesel for 1hr, passed . Levels remained <br /> 91 at 13" and diesel at 14" <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 A,/ Alii <br /> If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = Cal'domia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />