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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test Repair Test 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10181655 2/12/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As . ) <br /> Chevron 372736 <br /> Business Site Address City: Zip: <br /> 9484 West Lane Stockton 95210 <br /> IL 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 /> Industry Code or Engineering Standard : (Specify) PEI RP 1200 <br /> 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 : Regular Fill T1 : PREM . Fill T3 : diesel <br /> REGULAR PREMIUM Diesel <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Non-Metallic Non-Metallic Non-Metallic r Non-Metallic <br /> Method of Cathodic Protection r Isolation Isolation 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 . 5 16 16 <br /> Does the spill container have a 5 gallon capacity? W Yes r No r Yes r No W Yes r No r Yes r No <br /> Drain Valve Drain Valve WDrain 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 r Pass r Fail WPass r Fail ry, 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 /> 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 /> 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 />