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HomeMy WebLinkAboutSpill Bucket 2020Appendix 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 XXXX12 Month 1. FACILITY INFORMATION CERS ID 10022869 Test Date 12/16/2020 Facility Name Circle K Facility Address 5634 Stine Rd. City Bakersfield ZIP Code 93313 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 A. 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 Certification #0178497 06/24/2021 FFS EVR Phase 1 Systems # 1012513711 11/11/2021 4. TEST PROCEDURE INFORMATION Test Procedures Used Components Tested 1 HR. Lake Test 87, 91 Fill spill 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 12/16/2020 Total # of Pages 6.SPILL CONTAINER DETAILS Test Method Developed by ☐☐☐☐ Manufacturer XXXX Industry Standard ☐☐☐☐ Professional Engineer Underground Storage Tank Spill Container Testing Report Form Additional copies of this page may be attached. Page 2 of 2 Test Type ☐☐☐☐ Pressure ☐☐☐☐ Vacuum XXXX Hydrostatic Tank ID 87 91 Spill Container Manufacturer: OPW OPW Method of Cathodic Protection XXXXNonmetallic ☐☐☐☐Other XXXXNonmetallic ☐☐☐☐Other ☐☐☐☐Nonmetallic ☐☐☐☐Other ☐☐☐☐Nonmetallic ☐☐☐☐Other Is the spill container minimum capacity five gallons excluding riser volume? XXXXYes ☐☐☐☐No* XXXXYes ☐☐☐☐No* ☐☐☐☐Yes ☐☐☐☐No* ☐☐☐☐Yes ☐☐☐☐No* Method to keep spill container empty XXXXDrain ☐☐☐☐Pump ☐☐☐☐Other XXXXDrain ☐☐☐☐Pump ☐☐☐☐Other ☐☐☐☐Drain ☐☐☐☐Pump ☐☐☐☐Other ☐☐☐☐Drain ☐☐☐☐Pump ☐☐☐☐Other Spill Container Test Results XXXXPass ☐☐☐☐Fail XXXXPass ☐☐☐☐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 allanswers 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.