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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 Fx1 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181337 2 /22 / 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> CD & R - TRACY BLVD CHEVRON <br /> Business Site Address City ZIP Code <br /> 3775 TRACY BLVD TRACY , CA 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 /> EDWARD STEARNS ( 209 ) 744-0112 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 9/30/20 888308MT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 1009893708 Ex . 11 /29/2020 <br /> OPW # 104-635 Ex . 3/ 14/2020 <br /> Ill . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑x Manufacturer Guidelines (Specify) : LAKE TEST <br /> ❑ Industry Code or Engineering Standard (Specify) : <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.) 87 91 DIESEL <br /> Spill Container Manufacturer: PHIL TITE PHIL TITS PHIL TITS <br /> Method of Cathodic Protection : ❑x Non-Metallic Z Non-Metallic ❑x Non-Metallic ❑ Non-Metallic <br /> ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (specify in V.) ❑ Other (specify in V.) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 11 11 11 <br /> Depth of Spill Container: (Inches) 12 12 12 <br /> Does the spill container have a 5 gallon capacity? ❑ Yes ❑x No ❑ Yes R No ❑ Yes x❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve 0 Drain Valve ❑x Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (specifyin V.) ❑ Other (specify in V.) ❑ Other (Specify in V.) ❑ Other (Specifyin V.) <br /> lV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results : ❑x Pass ❑ Fail M Pass ❑ Fail ❑ Pass ❑x Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. <br /> DIESEL BUCKET FAILED LAKE TEST. ALL 3 BUCKETS DO NOT HOLD 5 GALLONS . <br /> a <br /> a <br /> � ! 4t 1 11 ! <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> hereby certify that the spill containers were tested in accordance with California � 1° ti sOifitie4 ;* V ` 11ion 3, <br /> Chapter 16 , Section 2637 . 1 and all the information contained herein is accurate. i FP B1N/7 E NI <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 = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Coundi <br />