Laserfiche WebLink
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 />UNDERGROUNDSTORAGETANK <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. FACILfiY1NFORMATION <br />CERS ID <br />Date of Spill Container Test: <br />10186665 <br />3/20/2019 <br />Business Name (Same as Facility Name or DBA -Doing Business As.) <br />CHEVRON 307709 <br />Business Site Address <br />City: <br />Zip: <br />10858 TRINITY PKWY <br />STOCKTON <br />95219 <br />II. 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 />Tanknology Certification -Level III Spill Container Testing Certification Exam 115240 07/06/2019 <br />ICC - CA UST Service Technician 8361393 <br />06/16/2019 <br />i 111. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: Manufacturer Guidelines: (Specify) <br />Iv Industry Code or Engineering Standard: (Specify) PEI RP 1200 <br />Engineered Method: (Specify) <br /># of Attached Pages <br />Attach the testing procedures and all documentation required to determine the results. <br />Fill T1 <br />Fill T-2 <br />Fill T-3 <br />Tank ID: (ey tank number, stored product, etc.) <br />UNLEADED <br />PREMIUM <br />Diesel <br />Spill Container Manufacturer: <br />OPW <br />OPW <br />OPW <br />� Non-Mettalic <br />Non-Mettalic <br />r Non-Mettalic <br />r Non-Mettalic <br />� Isolation <br />Isolation <br />� Isolation <br />� Isolation <br />Method of Cathodic Protection <br />Other <br />� Other <br />� Other <br />r 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 />� Onsite Pump <br />r Onsite Pump <br />� Onsite Pump <br />Method to Keep Spill Container Empty <br />� Other <br />� Other <br />r Other <br />� Other <br />(Specify in section V) <br />(Specify in section � <br />(Specify in section V) <br />Specify in section V) <br />N. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results <br />Pass � Fail <br />Pass Fail <br />�'�Pass �� Fail <br />�PBSS �€ Fail <br />Y. COMMENTSi <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 />1 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 />��: <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 />