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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) Type of Action ❑ Installation Test Z Repair Test ❑ 12 Month Test I. FACILITY INFORMATION CERS ID Date of Spill Container Test 10181251 11/14/2019 Business Name(Same as Facility Name or DBA-Doing Business As) CD&R-Tracy Boulevard Chevron Business Site Address City ZIP Code 3775 North Tracy Boulevard Tracy 95376 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# Benjamin Duncan (707) 621-0378 Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date Tank Tester License #90-1120 5246802-UT 3/21/2021 Spill Container Testing Training and Certifications(List applicable certifications.) ICC Service Technician#5246802-UT/Caldwell Systems/Level Change Indicator certification expires 7/5/2020. III. SPILL CONTAINER TESTING INFORMATION Test Method Used: ❑Manufacturer Guidelines(Specify): ❑ Industry Code or Engineering Standard (Specify): ❑x Engineered Method(Specify): Caldwell Systems/Hydrostatic/ 30 Minutes Attach the testing procedures and all documentation required to determine the results. #of Attached Pages2 TANK ID: (By tank number,stored product,etc.) T-1-Diesel T-2-91 T-3-87 Spill Container Manufacturer: OPW OPW OPW Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic Z Non-Metallic ❑ Non-Metallic ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V) Inside Diameter of Spill Container:(Inches) 1 1" 1 1" 1 ill Depth of Spill Container: (Inches) 15" 1511 15" Does the spill container have a 5 gallon capacity? 2 Yes ❑No [j]Yes ❑No El Yes ❑ No ❑Yes ❑No Method to Keep Spill Container Empty: ❑x Drain Valve ❑x Drain Valve ix Drain Valve ❑ Drain Valve ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results: ZPass ElFail ❑x Pass ❑Fail 0 Pass ❑Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked"Fail'above must be explained in this section. Any additional comments may also be provided here. Note: After i removed the Test Water from all three Spill Buckets, I poured a small amount of Gasoline into each Spill Bucket and Tested the functionality of all three drain valves. All three drain valves functioned properly and allowed the Gasoline to drain back to the Tank. Note: Spill Buckets are not direct bury, and are contained in Fill Riser Sumps. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations, Title 23, Division 3, Chapter 16,Section 2637.1 and all the information contained herein is accurate. UST Service Technician Signature 2ettjamit2 S Duncan U If the facility has more components than this form accommodates,additional copies of this page may be attached. CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=Intemational Code Council