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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page-I of 1) <br /> Type of Action ❑ Installation Test 0 Repair Test ❑ 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181251 11/14/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> CD&R-Tracy Boulevard Chevron <br /> Business Site Address City ZIP Code <br /> 3775 North Tracy Boulevard 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.) P75 <br /> hone# <br /> Benjamin Duncan (707) 621-0378 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Tank Tester License #90-1120 5246802-UT 3/21/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> ICC Service Technician#5246802-UT/Caldwell Systems/Level Change Indicator certification expires 7/5/2020. <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer Guidelines(Specify): <br /> ❑Industry Code or Engineering Standard (Specify): <br /> 0 Engineered Method (specify): Caldwell Systems/Hydrostatic/ 30 Minutes <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages2 <br /> TANK ID: (By tank number,stored product,etc.) T-1-Diesel T-2-91 T-3-87 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: 0 Non-Metallic 0 Non-Metallic 0 Non-Metallic ❑Non-Metallic <br /> ❑ Isolation ❑Isolation ❑ Isolation ❑Isolation <br /> ❑Other(Specify in v.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container:(Inches) 1 1" 1 1" 1 ill <br /> Depth of Spill Container: (Inches) 1511 1511 1511 <br /> Does the spill container have a 5 gallon capacity? El Yes ❑ No 0 Yes ❑No 0 Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: 0 Drain Valve 0 Drain Valve 0 Drain Valve 1 ❑Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in V.) ❑Other(Specify in V) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: 0 Pass ❑ Fail 0 Pass ❑Fail 0 Pass ❑Fail 11 ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked"Fail'above must be explained in this section. Any additional comments may also be provided here. <br /> Note: After i removed the Test Water from all three Spill Buckets, I poured a small amount of Gasoline into each Spill <br /> Bucket and Tested the functionality of all three drain valves. All three drain valves functioned properly and allowed the <br /> Gasoline to drain back to the Tank. <br /> Note: Spill Buckets are not direct bury, and are contained in Fill Riser Sumps. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING,._ HI$TESTING <br /> I hereby certify that the spill containers were tested in accordance with California Code of kedlulations, Title 23, Division.; <br /> Chapter 16,Section 2637.1 and all the information contained herein is accurate. <br /> UST Service Technician Signature 3wja ih 9 `.Dante <br /> G 2020 <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Califomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=Intemational Code` , I R O N M E N T A L HEALTH <br /> DEPARTMENT <br />