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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM(Page 1 of 1) <br /> Type of Action r Installation Test r Repair Test r 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10181657 1/10/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> CHEVRON#201383(N-2515-1-1) <br /> Business Site Address City: Zip: <br /> 1960 W. 11 TH STREET @ CORRAL HOLLOW TRACY 95376 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> Jesus Saldivar (800)800-4633 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Class A General Engineering 743160 8361393 6/13/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> ICC-CA UST Service Technician 8361393 06/13/2021 Tanknology Certification-Level III Spill Container Testing Certification Exam 115240 <br /> 06/09/2022 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: r Manufacturer Guidelines: (Specify) <br /> ry-1 Industry Code or Engineering Standard: (Specify) PEI RP 1200 <br /> F Engineered Method: (Specify) <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> Tank ID: (By tank number, stored product, etc.) Fill T2 Fill T1 Fill T3 <br /> REGULAR SUPREME Diesel <br /> Spill Container Manufacturer: OPW OPW OPW <br /> F Non-Metallic F Non-Metallic F Non-Metallic r Non-Metallic <br /> Method of Cathodic Protection r Isolation r Isolation r Isolation r Isolation <br /> F Other r Other r Other r Other <br /> (Specify in section V) (Specify in section V) (Specify in section V) Specify in section V) <br /> Inside Diameter of Spill Container: (Inches) 12 12 12 <br /> Depth of Spill Container: (Inches) 16 16 16 <br /> Does the spill container have a 5 gallon capacity? r Yes r No FV Yes r No r Yes r No r Yes r No <br /> W Drain Valve r Drain Valve F-0 Drain Valve r Drain Valve <br /> Method to Keep Spill Container Empty r Onsite Pump r Onsite Pump r Onsite Pump r Onsite Pump <br /> F Other r Other r Other r Other <br /> Specify in section V) (Specify in section V) Specify in section V) Specify in section V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results 1-Pass r Fail I FVPass r Fail P'PaSS r Fail rPass r Fail <br /> V. COMMENTS <br /> All items marked failed above must be explained in this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations,title 23,division 3,chapter 16,section <br /> 2637.1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> ,A 4w_ <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council <br />