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UNDERGROUND STORAGE TANK <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 /> 3/26/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Chevron <br /> Business Site Address City ZIP Code <br /> 2615 Grantline Rd Tracy 95304 <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 /> Jeff Conger (707 ) 386 - 7573 Ext. <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 90 - 1116 1081782 1 /24/21 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW # 104789 Exp 4/ 1 /2021 FFS EVR Phase I - VR101 ( Phil -tite) # 1020003708 Exp 4/10/2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : <br /> ® Manufacturer Guidelines : (Specify) FFS Installation guide <br /> ❑ Industry Code or Engineering Standard : (Specify) PEI <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.) # 1 - Supreme #2- Diesel #3 - Regular <br /> Spill Container Manufacturer: Philtite Philtite Philtite <br /> ® Non-Metallic ® Non-Metallic ® 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) 11 11 13 <br /> Depth of Spill Container: (Inches) 173/8 157/8 143/4 <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No ® Yes ❑ No M Yes ❑ No ❑ Yes ❑ No <br /> ® Drain Valve ® Drain Valve ® 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 ® Pass ❑ Fail I M Pass ❑ Fail ® Pass ❑ Fail ❑ 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 /> Inspector Shewit Woldearegay was on site . <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I 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 />