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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 x❑ 12 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10186995 11 /21 /2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Chevron <br /> Business Site Address City ZIP Code <br /> 1916 E . March Lane 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 /> Chris Bishop ( 916) 3824761 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 8216429 5/2/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> His SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> p Industry Code or Engineering Standard (Specify): LAKE TEST FOR 1 HOUR . <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.) 87 91 DIESEL <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic ❑ Non-Metallic <br /> 0 Isolation R Isolation I] Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) ❑ Other (Specify in V.) <br /> Inside Diameter of Spill Container: (Inches) 12 . 00" 12 . 00" 12 . 00" <br /> Depth of Spill Container: (Inches) 12 . 75." . 15 . 50" 14 . 00" <br /> Does the spill container have a 5 gallon capacity? 0 Yes ❑ No 9 Yes ❑ No El Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑x Drain Valve Z Drain Valve Q Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> i <br /> ❑ Other (Specify in V.) ❑ Other (Specify in V.) I ❑ Other (Specify in V.) A ❑ Other (Specify in V) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: Q Pass ❑ Fail [E Pass ❑ Fail El Pass ❑ Fail ❑ Pass ❑ Fail <br /> i <br /> V. COMMENTS <br /> Any items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. <br /> i <br /> i <br /> VL CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 1 hereby certify that the spill containers ere tested in accordance with California Code of Regulations, Title 23 , Division 3, <br /> Chapter 16 , Section 2637. 1 and all the in rmati n contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components t n this form ccommodates, additional copies of this page may be attached. <br /> i <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br /> i <br />