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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Pagel of 1) <br /> Type of Action ❑ Installation Test ❑ Repair Test <br /> ❑ 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10184563 4/23/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Chevron 212470 <br /> Business Site Address City ZIP Code <br /> 3400 N MacArthur Dr 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 /> Nick Harvey (714) 826- 0352 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 300345 A B C61/D40 HAZ 5115738 01/11/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑Manufacturer Guidelines:(Specify) <br /> ® Industry Code orEngineering Standard:(Specify) PEI RP1200 <br /> ❑Engineered Method:(Specify) <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> Tank I D:(By tank number,stored product,etc.) 87 FIII 91 Fill Diesel Fill <br /> Spill Container Manufacturer: OPW OPW OPW <br /> N Non-Metallic Z Non-Metallic E Non-Metallic ❑Non-Metallic <br /> Method of Cathodic Protection ❑Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other ❑Other ❑Other ❑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) <br /> 12" 12" 12" <br /> Depth of Spill Container:(Inches) 15" 15" 15" <br /> Does the spill container have a 5 gallon capacity? N Yes ❑No E Yes ❑No E Yes ❑No ❑Yes ❑No <br /> Z Drain Valve Z Drain Valve N Drain Valve ❑Drain Valve <br /> Method to Keep Spill Container Empty ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other ❑Other ❑Other ❑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 Z Pass El=Fail Pass ❑ Fail Z Pass ❑ Fail 11 ❑Pass ❑ Fail <br /> V. COMMENTS <br /> All items marked"Fail'above must be explained in this section.Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 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. I ` <br /> UST Service Technician Signature N �I,`1' <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 />