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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 /> 10181655 11 /06/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Chevron 372736 <br /> Business Site Address City ZIP Code <br /> 9484 West Ln Stockton 95210 <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 /> Nick Harvey (916) 834 - 5099 Ext. <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 300345 A B C61 /D40 HAZ 5115738 01 / 11 /2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : <br /> ❑ Manufacturer Guidelines : (Specify) <br /> ® Industry Code or Engineering Standard : (Specify) PEI RP1200 <br /> ❑ Engineered Method : (Specify) <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages <br /> Tank to : (By tank number, stored product, etc.) 87 Fill 91 Fill Diesel Fill <br /> Spill Container Manufacturer: OPW OPW OPW <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) <br /> 12 " 12 12 " <br /> Depth of Spill Container: (Inches) 16 " 16 16 " <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No <br /> ® Drain Valve ® Drain Valve ® Drain Valve ❑ Drain Valve <br /> Method to Keep Spill Container Empty <br /> [I Onsite Pump ❑ Onsite Pump El Onsite Pump El 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 117 Pass ❑ Fail ® 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 /> 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. t t <br /> UST Service Technician Signature U <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 />