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UNDERGROUNDSTORAGETANK' <br />-_ <br />SPILL CONTAINER TESTING REPORT FORM {Page 1 <br />of 1) <br />Type of Action Installation Test � Repair Test <br />�' 12 Month <br />Test <br />1. FACILITY INFORMATION <br />CERS ID <br />Date of Spill Container Test: <br />10181335 <br />2/25/2019 <br />Business Name (Same as Facility Name or DBA -Doing Business As.) <br />CHEVRON # 94275 <br />Business Site Address <br />City: <br />Zip: <br />2905 W. BENJAMIN HOLT @ I-5 <br />STOCKTON <br />95207 <br />11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) <br />Phone # <br />Jesus Saldivar <br />(800) 800-4633 <br />Contractor/Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />Class A General Engineering 743160 <br />8361393 <br />6/16/2019 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />ICC - CA UST Service Technician 8361393 06/16/2019 Tanknology Certification -Level III Spill Container Testing Certification <br />Exam 115240 <br />07/06/2019 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: Manufacturer Guidelines: (Specify) <br />�' Industry Code or Engineering Standard: (Specify) PEI RP 1200 <br />Engineered Method: (Specify) <br /># <br />of Attached Pages <br />Attach the testing procedures and all documentation required to determine the results. <br />Fill T2 <br />Fill T1 <br />Fill T3 <br />Tank ID: (ey tank number, stored product, etc.) <br />REG UNLEAD <br />SUPREME <br />DIESEL2 <br />Spill Container Manufacturer: <br />Franklin/EBW <br />Franklin/EBW <br />Franklin/EBW <br />� Non-Mettalic <br />Non-Mettalic <br />Non-Mettalic <br />� Non-Mettalic <br />� Isolation <br />� Isolation <br />� Isolation <br />� Isolation <br />Method of Cathodic Protection <br />� Other <br />� Other <br />� Other <br />� Other <br />Specify in section V) <br />(Specify in section V) <br />(Specify in section V) <br />(Specify in section V) <br />Inside Diameter of Spill Container: (Inches) <br />12 <br />12 <br />12 <br />Depth of Spill Container: (Inches) <br />12 <br />12 <br />12 <br />Does the spill container have a 5 gallon capacity? <br />Yes � No <br />� Yes � No <br />� Yes � No <br />� Yes � No <br />� Drain Valve <br />� Drain Valve <br />� Drain Valve <br />� Drain Valve <br />� Onsite Pump <br />r Onsite Pump <br />� Onsite Pump <br />� Onsite Pump <br />Method to Keep Spill Container Empty <br />� Other <br />� Other <br />� Other <br />� Other <br />(Specify in section V) <br />(Specify in section V) <br />(Specify in section V) <br />Specify in section V) <br />N. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results <br />!�' P2SS � Fail � Pass � Fail <br />� Pass � Fail <br />�PflSS Fail <br />V. COMMENTS <br />All items marked failed above must be explained in this section. Any additional comments may also be provided here. <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN .CONDUCTING THIS <br />hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 23, division <br />3, chapter 16, section <br />2637.1 and all the information contained herein is accurate. <br />UST Service Technician Signature <br />�" " V �,�� <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 />