HomeMy WebLinkAboutOVERFILL 2020
Appendix VIII
Underground Storage Tank
Spill Container Testing Report Form
CERS = California Environmental Reporting System, ID = Identification, ICC = International Code
Council
Page 1 of 2
TYPE OF ACTION ☐ Installation ☐ Repair ☒ 12 Month
1. FACILITY INFORMATION
CERS ID
10023802
Test Date
11/19/2020
Facility Name
CIRCLE K # 2708605
Facility Address
5600 AUBURN
City
BAKERSFIELD
ZIP Code
93306
2. SERVICE TECHNICIAN INFORMATION
Company Performing the Test
B&T SERVICE STATION CONTRACTORS
Phone
805-929-8944
Mailing Address
630 S FRONTAGE RD NIPOMO, CA. 93444
Service Technician Performing Test
MICHAEL MOLACEK
Contractor/Tank Tester License Number
902034
ICC Number
9175943
ICC Expiration Date
11/15/2021
3. TRAINING AND CERTIFICATIONS
Manufacturer and Test Equipment Training Certifications Expiration Date
OPW EVR UST 0178491 06/24/2021
4. TEST PROCEDURE INFORMATION
Test Procedures Used Components Tested
RP1200 87 , 91 FILL BUCKETS
5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST
I hereby certify that each spill container was tested in accordance with California Code of
Regulations, title 23, division 3, chapter 16, section 2637.1; that required supporting
documentation is attached; and all information contained herein is accurate. I understand
that test procedures shall be made available upon request by the governing authority.
Service Technician Signature Date
11/19/2020
Total # of Pages
Underground Storage Tank
Spill Container Testing Report Form
Additional copies of this page may be attached.
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6. SPILL CONTAINER DETAILS
Test Method Developed by ☐ Manufacturer ☒ Industry Standard ☐ Professional Engineer
Test Type ☐ Pressure ☐ Vacuum ☒ Hydrostatic
Tank ID 87 91
Spill Container Manufacturer: OPW OPW
Method of Cathodic Protection ☒ Nonmetallic
☐ Other
☒ Nonmetallic
☐ Other
☐ Nonmetallic
☐ Other
☐ Nonmetallic
☐ Other
Is the spill container minimum
capacity five gallons excluding
riser volume?
☒ Yes
☐ No*
☒ Yes
☐ No*
☐ Yes
☐ No*
☐ Yes
☐ No*
Method to keep spill container
empty
☒ Drain
☐ Pump
☐ Other
☒ Drain
☐ Pump
☐ Other
☐ Drain
☐ Pump
☐ Other
☐ Drain
☐ Pump
☐ Other
Spill Container Test Results ☒ Pass
☐ Fail
☒ Pass
☐ Fail
☐ Pass
☐ Fail
☐ Pass
☐ Fail
Tank ID
Spill Container Manufacturer:
Method of Cathodic Protection ☐ Nonmetallic
☐ Other
☐ Nonmetallic
☐ Other
☐ Nonmetallic
☐ Other
☐ Nonmetallic
☐ Other
Is the spill container minimum
capacity five gallons excluding
riser volume?
☐ Yes
☐ No*
☐ Yes
☐ No*
☐ Yes
☐ No*
☐ Yes
☐ No*
Method to keep spill container
empty
☐ Drain
☐ Pump
☐ Other
☐ Drain
☐ Pump
☐ Other
☐ Drain
☐ Pump
☐ Other
☐ Drain
☐ Pump
☐ Other
Spill Container Test Results ☐ Pass
☐ Fail
☐ Pass
☐ Fail
☐ Pass
☐ Fail
☐ Pass
☐ Fail
1 8. COMMENTS
Describe all answers marked “Other,” “No,” or “Fail” and each proposed remedy.
* Mark here if:
Spill containers do not have a minimum capacity of five gallons and require replacement.