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 /> 5/9/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Arco <br /> Business Site Address City ZIP Code <br /> 14931 Flag City Blvd Lodi , CA . <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 /> Brian Roth ( 916 ) 3824761 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 949066 8834817 10/ 19/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> 21 Industry code or Engineering Standard (specify): Hydrostatic with measurement for 1 hr no drop <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) 12 12 12 " <br /> Depth of Spill Container: (Inches) 11 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No El Yes ❑ No El 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 ❑ Fail ❑x Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail " above must be explained in this section. Any additional comments may__a/so be provided here. <br /> it <br /> �My � 3 2019 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDU ING T1 48118S INO I F ,A, I _TH <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulatl6ris , 1 Title 23 Division 3, <br /> Chapter 16 , Section 2637 . 1 and all the informati n contained herein is accurate . <br /> UST Service Technician Signature <br /> r � <br /> If the facility has more components than th! orm accommodates, additional copies of this page may be attached. <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />