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HomeMy WebLinkAboutFMC 2023 Spill BucketsAppendix 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 Test Date Facility Name Facility Address City ZIP Code 2. SERVICE TECHNICIAN INFORMATION Company Performing the Test Phone Mailing Address Service Technician Performing Test Contractor/Tank Tester License Number ICC Number ICC Expiration Date 3.TRAINING AND CERTIFICATIONS Manufacturer and Test Equipment Training Certifications Expiration Date 4.TEST PROCEDURE INFORMATION Test Procedures Used Components Tested 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 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 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 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.