HomeMy WebLinkAboutGENERATOR SPILL BUCKET 2018
UNDERGROUND STORAGE TANK
SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1)
Type of Action Installation Test Repair Test 12 Month Test
I. FACILITY INFORMATION
CERS ID Date of Spill Container Test
Business Name (Same as Facility Name or DBA-Doing Business As)
Business Site Address City ZIP Code
II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION
Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone #
Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date
Spill Container Testing Training and Certifications (List applicable certifications.)
III. SPILL CONTAINER TESTING INFORMATION
Test Method Used: Manufacturer Guidelines (Specify):
Industry Code or Engineering Standard (Specify):
Engineered Method (Specify):
Attach the testing procedures and all documentation required to determine the results. # of Attached Pages
TANK ID: (By tank number, stored product, etc.)
Spill Container Manufacturer:
Method of Cathodic Protection: Non-Metallic Non-Metallic Non-Metallic Non-Metallic
Isolation Isolation Isolation Isolation
Other (Specify in V.) Other (Specify in V.) Other (Specify in V.) Other (Specify in V.)
Inside Diameter of Spill Container: (Inches)
Depth of Spill Container: (Inches)
Does the spill container have a 5 gallon capacity? Yes No Yes No Yes No Yes No
Method to Keep Spill Container Empty: Drain Valve Drain Valve Drain Valve Drain Valve
Onsite Pump Onsite Pump Onsite Pump Onsite Pump
Other (Specify in V.) Other (Specify in V.) Other (Specify in V.) Other (Specify in V.)
IV. SUMMARY OF TESTING RESULTS
Spill Container Test Results: Pass Fail Pass Fail Pass Fail Pass Fail
V. COMMENTS
Any items marked “Fail” above must be explained in this section. Any additional comments may also be provided here.
VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING
I hereby certify that the spill containers were tested in accordance with California Code of Regulations, Title 23, Division 3,
Chapter 16, Section 2637.1 and all the information contained herein is accurate.
UST Service Technician Signature
If the facility has more components than this form accommodates, additional copies of this page may be attached.
CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council