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UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action Installation Test r Repair Test lvl, 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID Date of Spill Container Test: <br />10181341 11/15/2018 <br />Business Name (Same as Facility Name or DBA -Doing Business As.) <br />CHEVRON #99840 (N31) <br />Business Site Address City: Zip: <br />4344 E WATERLOO RD @ 99 STOCKTON 95215 <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 />Jarrod Cooke (800) 800-4633 <br />Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />Class A General Engineering 743160 5311523 -UT 4/6/2019 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - PhikTite EVR Ph 1 Systems 1004023708 05/07/2020 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: Manufacturer Guidelines: (Specify) <br />Industry Code or Engineering Standard: (Specify) PEI RP 1200 <br />r Engineered Method: (Specify) <br />Attach the testing procedures and all documentation required to determine the results. # of Attached Pages <br />&nbspl <br />Tank ID: (By tank number, stored product, etc.) Fill T1 Fill T2 <br />SUPREME REG UNLEAD <br />Spill Container Manufacturer: Franklin/EBW Franklin/EBW <br />r Non-Mettalic r Non-Mettalic Non-Mettalic Non-Mettalic <br />Method of Cathodic Protection Isolation r Isolation r Isolation r Isolation <br />r Other r Other r Other r 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) 12 12 <br />Depth of Spill Container: (Inches) 14 14 <br />Does the spill container have a 5 gallon capacity? FV Yes r No r'Yes r No rYeS r No rYeS r No <br />r Drain Valve r Drain Valve r Drain Valve r Drain Valve <br />Method to Keep Spill Container Empty r Onsite Pump r Onsite Pump r Onsite Pump r Onsite Pump <br />r Other r Other r Other r 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 WPass r Fail (":Pass r Fail rpass F Fail Pass 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 />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. <br />UST Service Technician Signature <br />If the facility <br />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 />