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 /> 12 / 13/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Flyers #427 <br /> Business Site Address City ZIP Code <br /> 3300 Waterloo Road Stockton 95205 <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 /> Anthony Reyes ( 916 ) 372 - 1885 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 617238 8293772 9/ 16 /2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW Tech# 103920 , PhikTite Tech# 1003213709 <br /> R E <br /> r,��-� <br /> ;� :r'; , , <br /> Z LD <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify) : Lake Test <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> I j <br /> ❑ Engineered Method (Specify) : f! 1- Ahti- Pili <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> TANK ID : (By tank number, storedproduct, etc.) FNon-Metallic <br /> soline Diesel Red Diesel <br /> Spill Container Manufacturer: W OPW OPW <br /> Method of Cathodic Protection : ❑ Non-Metallic ❑ Non- Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑x Other (Specify in V.) El Other (Specify in v.) ❑x Other (Specify in V.) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 11 . 5 11 . 5 11 . 5 <br /> Depth of Spill Container: (Inches) 13 . 5 15 13 <br /> Does the spill container have a 5 gallon capacity? R Yes ❑ No ❑x Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve LDDrainValve ❑x Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in V.) (Specify in V.) tj ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ❑Q 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 also be provided here. <br /> Method of Cathodic Protection is unknown , or they are not protected . <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 /> rt <br /> If the facility has more components than this form 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 />