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RECEIVED <br /> UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM SEP 0 4 2020 <br /> Type of Action ❑ Installation Test ® Repair Test ah <br /> SFF-,s IA .. I <br /> I. FACILITY INFORMATION <br /> CERS ID: <br /> TDate: <br /> Business Name <br /> 8/28/2020&8/31/2020 <br /> Chevron <br /> Business Site Address City Zip Code <br /> 444 Mossdale Road Lathrop <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION _ <br /> Business Name&Address: BZ Service Station Maintenance—1041 Triangle Ct,West Sacramento CA <br /> Name of UST Service Technician Performing the Test Rhome Desbiens Phone# 916-371-2380 <br /> Contractor License# 433159 ICC Certification# 5244364 ICC Expiration Date 1/4/2021 <br /> Spill Container Testing Training and Certification(List applicable certification.) <br /> OPW UST/AST-100656 ex 5/8/2022 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑Manufacturer(Specify): <br /> ®Industry Code or Engineering Standard(Specify): PEI 1200 Pg.it <br /> Hydrostatic Engineered Method(Specify): <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages: <br /> TANK ID:(By tank#, stored product, etc) 8/28/2020-87 8/28/2020-91 8/31/2020-87 8/31/2020-91 <br /> Spill Container Manufacturer: OPW OPW DPW OPW <br /> Method of Cathodic Protection: ® Non-Metallic ® Non-Metallic ® Non-Metallic ® Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> Inside Diameter of Spill Container:(Inches) 11" <br /> Depth of Spill Container:(Inches) 13" 12.5" 13.5" 13" <br /> Does the spill container have a 5 gallon ® Yes ❑ No ® Yes ❑ No Z Yes 0 No ® Yes ❑ No <br /> capacity? <br /> Method to Keep Spill Container Empty: Drain Value Drain Value Drain Value Drain Value <br /> El onsite Pump F-1OnsitePump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other ❑ Other ❑ Other ❑ Other <br /> IV, SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ® Pass ❑ Fail ® Pass ❑ Fail ® Pass Fail ® 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 /> 8/28/2020-Pre backfill bucket test-passed. <br /> 8/31/2020-With one inspector and two inspector trainees,conducted 87 and 91 spill bucket and drain valve tests.Tests <br /> passed. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN_CONDUCTING THIS TESTING <br /> I hearby 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 />