California Code of Regulations › Title 23 - Waters › Division 3 - State Water Resources Control Board and Regional Water Quality Control Boards › Chapter 16 - Underground Tank Regulations › Appendix VIII - Underground Storage Tank Spill Container Testing Report Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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
___________________________
CERS = California Environmental Reporting System, ID =
				  Identification, ICC = International Code Council
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
[] Nonmetallic
[] Nonmetallic
[] Nonmetallic
[] Other
[] Other
[]
						  Other
[] Other
Is the spill container minimum capacity five gallons
						  excluding riser volume
[] Yes
[] Yes
[] Yes
[] Yes
[] No*
[] No*
[]
						  No*
[]
						  No*
Method to keep spill container empty
[]
						  Drain
[] Drain
[] Drain
[] Drain
[] Pump
[] Pump
[]
						  Pump
[] Pump
[] Other
[] Other
[]
						  Other
[] Other
Spill Container Test Results
[] Pass
[] Pass
[] Pass
[] Pass
[] Fail
[] Fail
[]
						  Fail
[] Fail
Tank ID
Spill Container Manufacturer:
Method of Cathodic Protection
[]
						  Nonmetallic
[] Nonmetallic
[] Nonmetallic
[] Nonmetallic
[] Other
[] Other
[]
						  Other
[] Other
Is the spill container minimum capacity five gallons
						  excluding riser volume
[] Yes
[] Yes
[] Yes
[] Yes
[] No*
[] No*
[]
						  No*
[]
						  No*
Method to keep spill container empty
[]
						  Drain
[] Drain
[] Drain
[] Drain
[] Pump
[] Pump
[]
						  Pump
[] Pump
[] Other
[] Other
[]
						  Other
[] Other
Spill Container Test Results
[] Pass
[] Pass
[] Pass
[] Pass
[] Fail
[] Fail
[]
						  Fail
[] Fail
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.
Additional copies of this page may be
				  attached.
1. New
				  Appendix VIII filed 8-27-2018; operative 10-1-2018 (Register 2018, No.
				  35).
2. Repealer and new appendix filed 8-27-2020; operative
				  10-1-2020 (Register 2020, No. 35). Filing deadline specified in Government Code
				  section
				  11349.3(a)
				  extended 60 days pursuant to Executive Order N-40-20 and an additional 60 days
				  pursuant to Executive Order N-66-20.