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 /> 10181913 02/ 12/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Shell <br /> Business Site Address City ZIP Code <br /> 16500 S . Harlan Road Lathrop , CA 95330 <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 /> Nik Zagorov (888) 500 - 2435 Ext. 2 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 958763 5264361 05/08/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW Phase 1 EVR # 100908 exp . 04/06/2019 <br /> Iii . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : <br /> ❑ Manufacturer Guidelines : (Specify) <br /> ® Industry Code or Engineering Standard : (Specify) Hydrostatic One Hour Lake Test <br /> ❑ Engineered Method : (Specify) <br /> # <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 <br /> Spill Container Manufacturer: OPW OPW <br /> ® Non-Metallic ® Non-Metallic <br /> Method of Cathodic Protection ❑ Isolation ❑ Isolation <br /> ❑ Other ❑ Other <br /> (Specify in section V.) (Specify in section V) 16 <br /> Inside Diameter of Spill Container: (Inches) 12 12 <br /> Depth of Spill Container: (Inches) 14 14 <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No ® Yes ❑ No <br /> ® Drain Valve ® Drain Valve <br /> Method to Keep Spill Container Empty ❑ Onsite Pump E:1 Onsite Pump <br /> ❑ Other ❑ Other <br /> (Specify in section V) (Specify in section V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ® 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 /> idyl c r ov <br /> If the facility has more components than this f 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 />