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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type;ofction El Installation Test <br /> ❑ Repair Test 0 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID <br /> 10181345 Date of Spill Container Test <br /> 10/24/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> CHARTER WAY CHEVRON <br /> Business Site Address City ZIP Code <br /> 508 W CHARTER WAY STOCKTON , CA 95206 <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 /> FELIX RAMIREZ (209 ) 744-0112 <br /> Contractor i Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08 - 1740 5-31 -20 8883072- UT <br /> 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications) <br /> Franklin Fueling - EBW & Phil Tite # 1009883708 11 /29/20 <br /> OPW # 104634 3- 14-20 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify): <br /> ❑x Industry Code or Engineering Standard (Specify): <br /> LAKE TEST <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.) $ 7 91 87 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection : ❑x Non-Metallic ❑x Non=Metallic ❑x Non=Metallic <br /> ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Isolation <br /> ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) <br /> Inside Diameter of Spill Container: (inches) 11 11 11 <br /> Depth of Spill Container: (Inches) 15 15 15 <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑ No ❑x Yes ❑ No ❑x Yes <br /> Sill Container Em ❑ No ❑ Yes ❑ No <br /> Method to Keep p ptY ❑x Drain Valve ❑x Drain Valve ❑x Drain Valve <br /> ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump El Onsite Pump <br /> ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V) ❑ Other (Specifyin V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ❑x Pass ❑ Fail 11 ❑x Pass ❑ Fail ❑x Pass ❑ Fail <br /> ❑ Pass El V. COMMENTS <br /> Any items marked `Fail" above must be explained in this section. Any additional comments may also be provided here. <br /> RECEVE .1 <br /> I`i0V Q 7 2019 <br /> Vi . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the spill containers were tested in accordance with California CocElkll</ <br /> Chapter 16, Section 2637. 1 and all the information contained herein is accurate. ' <br /> UST Service Technician Signature /rd���� <br /> DEPARTMENTivrsron 3 <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />