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HomeMy WebLinkAbout2021-10-12-2701270-SBIAppendix 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 10022869 Test Date 10/12/2021 Facility Name Circle k Facility Address 5634 Stine rd City Bakersfield ZIP Code 2. SERVICE TECHNICIAN INFORMATION Company Performing the Test B&T Service Station Contractors Phone 805-929-8944 Mailing Address 630 S. Frontage rd Nipomo Service Technician Performing Test Rick Binger Contractor/Tank Tester License Number 902034 ICC Number 8452629 ICC Expiration Date 3/31/2023 3.TRAINING AND CERTIFICATIONS Manufacturer and Test Equipment Training Certifications Expiration Date OPW 1192309 7/2/2023 4.TEST PROCEDURE INFORMATION Test Procedures Used Components Tested RP1200 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 10/13/2021 Total # of Pages Underground Storage Tank Spill Container Testing Report Form Additional copies of this page may be attached. Page 2 of 2 6.SPILL CONTAINER DETAILS Test Method Developed by ☐ Manufacturer ☒ Industry Standard ☐ Professional Engineer Test Type ☐Pressure ☐Vacuum ☒Hydrostatic Tank ID Tank 1 87 Tank 2 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 ☐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. 10/12/2021 91 Spill Bucket failed to hod 5 gallons. * Mark here if: 10/13/2021 Underground Storage Tank Spill Container Testing Report Form Additional copies of this page may be attached. Page 3 of 2 Spill containers do not have a minimum capacity of five gallons and require replacement. 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 10022869 Test Date 10/13/2021 Facility Name Circle k Facility Address 5634 Stine rd City Bakersfield ZIP Code 2. SERVICE TECHNICIAN INFORMATION Company Performing the Test B&T Service Station Contractors Phone 805-929-8944 Mailing Address 630 S. Frontage rd Nipomo Service Technician Performing Test Rick Binger Contractor/Tank Tester License Number 902034 ICC Number 8452629 ICC Expiration Date 3/31/2023 3. TRAINING AND CERTIFICATIONS Manufacturer and Test Equipment Training Certifications Expiration Date OPW 1192309 7/2/2023 4. TEST PROCEDURE INFORMATION Test Procedures Used Components Tested RP1200 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 10/13/2021 Total # of Pages Underground Storage Tank Spill Container Testing Report Form Additional copies of this page may be attached. Page 2 of 2 6. SPILL CONTAINER DETAILS Test Method Developed by ☐ Manufacturer ☒ Industry Standard ☐ Professional Engineer Test Type ☐ Pressure ☐ Vacuum ☒ Hydrostatic Tank ID Tank 1 87 Tank 2 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. 10/12/2021 91 Spill Bucket failed to hod 5 gallons. 91 spill bucket was fixed during inspection for OPI a new nipple for 91 fill spill bucket was installed and both buckets where test and Passed * Mark here if: 10/13/2021 Underground Storage Tank Spill Container Testing Report Form Additional copies of this page may be attached. Page 3 of 2 Spill containers do not have a minimum capacity of five gallons and require replacement.