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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 /> 10181653 1 /8/2019 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> CHEVRON 201761 <br /> Business Site Address City: Zip : <br /> 1103 S. MAIN ST, PERMIT NUMB , W3315 MANTECA 95337 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test ( Print as shown on the ICC Certification . ) Phone # <br /> Jesus Saldivar (800) 8004633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8361393 6/16/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Tanknology Certification - Level III Spill Container Testing Certification Exam 115240 07/06/2019 ICC - CA UST Service Technician 8361393 <br /> 06/16/2019 <br /> 111. 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 /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages <br /> Tank ID : (By tank number, stored product, etc.) Fill T2 Regular 2 Fill T3 Regular 1 Fill T1 Supreme <br /> REGULAR REGULAR SUPREME <br /> Spill Container Manufacturer: Franklin/EBW Franklin/EBW Franklin/EBW <br /> W Non-Mettalic ry Non-Mettalic W Non-Mettalic Non- Mettalic <br /> Method of Cathodic Protection Isolation r Isolation r Isolation Isolation <br /> Other r Other F 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 12 <br /> Depth of Spill Container: ( Inches) 12 12 12 <br /> Does the spill container have a 5 gallon capacity? r' Yes W No r Yes W No r' Yes r No r Yes r No <br /> r Drain Valve Drain Valve Drain Valve Drain Valve <br /> Method to Keep Spill Container Empty Onsite Pump r Onsite Pump Onsite Pump Onsite Pump <br /> Other r 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 FPass W Fail FPass Wo Fail FPass W Fail FPass r7, 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 /> SPILL BUCKETS PASSED BUT DID NOT MEET THE FIVE GALLON CAPACITY. <br /> REPLACED FILL CAP ON 87 REG, SLAVE STP <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 3, chapter 16 , section <br /> 2637. 1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> i <br /> If the facility has more components than this form accommodates , additional copies of this page may be attached . <br /> I CERS=California Environmental Reporting System, ID=Identification , UST=Underground storage tank, ICC=International Code Council <br />