Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Pagel of 1) <br /> Type of Action ❑ Installation Test ❑Repair Test X 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10180881 7/29/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> BLACK HAWK PETROLEUM - TIGER EXPRESS #2 DELTA 99 <br /> Business Site Address City ZIP Code <br /> 5611 EAST WATERLOO ROAD STOCKTON, CA 195215 <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 /> FELIX RAMIREZ (209) 744-0112 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1740 5-31-20 8883072-UT 11/9/2020 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> Franklin Fueling -EBW& Phil Tite #1009883708 11/29/20 <br /> OPW#104634 3-14-20 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): LADE 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.) 87 91 DIESEL <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic X 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) 11 11 11 <br /> Depth of Spill Container:(Inches) 12 12 12 <br /> Does the spill container have a 5 gallon capacity? 9 Yes ❑No El Yes ❑No 0 Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve X Drain Valve ❑Drain Valve <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 ElFail ZPass ❑Fail 10 Pass ❑x Fail E]Pass El 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 /> RECEIVED <br /> �"'T 5 2019 <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—� <br /> If the facility has more components than this form accommodates,additional copies of this page maybe attached. <br /> CERS=Calffomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=Intemational Code Council <br />