Laserfiche WebLink
UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Test ❑ Repair Test ❑Q 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID Date of Spill Container Test <br />10181303 10/15/2018 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />ZOOM CAR WASH <br />Business Site Address City ZIP Code <br />3434 E. HAMMER LANE STOCKTON 95212 <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 I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />08-1740 5-31-20 8883072 -UT 11/22/2018 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tite #1009883708 11-16-18 la w "l <br />OPW #104634 3-14-20 R E 4 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: ❑ Manufacturer Guidelines (Specify): <br />OPW WATER /TAPE DEC 0 4 7018 <br />❑ Industry Code or Engineering Standard (Specify): ENVIRONMENTAL HEALTH <br />❑ Engineered Method (Specify): nEPd,rj1T ,., F N!T <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.) 87 91 DIESEL <br />Spill Container Manufacturer: PHIL TITE PHIL TITE PHIL TITE <br />Method of Cathodic Protection: 0 Non -Metallic 9 Non -Metallic Z 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) 14 14 14 <br />Does the spill container have a 5 gallon capacity? E Yes ❑ No 0 Yes ❑ No 9 Yes ❑ No ❑ Yes ❑ No <br />Method to Keep Spill Container Empty: 0 Drain Valve E) 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 (Specifyin V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: Z Pass ❑ Fail ❑ Pass ❑ Fail IF ❑ 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 />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 er <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 Counal <br />