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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Test ❑ Repair Test ❑Q 12 Month Test I . FACILITY INFORMATION D CERS ID ate of Spill Container Test 10594654 1 /21 /2020 Business Name (Same as Facility Name or DBA-Doing Business As) CRM - PACIFIC AVE CHEVRON Business Site Address City ZIP Code 6633 PACIFIC AVE STOCKTON , CA 95207 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # DAVID WINKLER 1 (209 ) 744-0112 Contractor i Tank Tester License # ICC Certification # ICC Certification Expiration Date 0 & 1739 Ex . 3/31 /20 8883059- UT 1 /29/2020 Spill Container Testing Training and Certifications (List applicable certifications.) Franklin Fueling - EBW & Phil Tite # 10009853708 Ex. 11 /29/20 OPW # 104-633 Ex. 3/14/2020 III . SPILL CONTAINER TESTING INFORMATION Test Method Used : ❑x Manufacturer Guidelines (Specify) : WATER TEST ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) 87 91 DSL Spill Container Manufacturer: PT PT PT Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic I] Non-Metallic ❑ Non-Metallic ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) Inside Diameter of Spill Container: (Inches) 12 12 12 Depth of Spill Container: (inches) 13 13 131 /2 Does the spill container have a 5 gallon capacity? 0 Yes ❑ No 0 Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve Z Drain Valve ❑ Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Other (Specify in V.) ❑ Other (SpeE L❑ Other (Specify in V) ❑ Other (Specify in V) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : ❑x Pass ❑ Fail (] Pass ❑ Fail ❑Q Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail' above must be explained in this section. Any additional comments may Ibe provided here . F Eu 12 2020 ENVIRONMENTAL HEALTH VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THISUES14 I hereby certify that the spill containers were tested in accordance with California Code of Regulations, Title 23, Division 3, Chapter 16, Section 2637.1 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council