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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test r Repair Test 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10182331 1 /17/2019 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> CHEVRON 208118 W4087- 1 -3 <br /> Business Site Address City: Zip: <br /> 3355 E. HAMMER LANE @ HOLMAN RD STOCKTON 95212 <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 /> Brent Bowen ( 800) 8004633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8211862 6/23/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - Phil-Tite EVR Ph 1 Systems 1004223708 01 /05/2021 CA - Tightness Testing 14 106/30/ 020 ; , s <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : r Manufacturer Guidelines : (Specify) FE <br /> i ), r <br />€ W4 Industry Code or Engineering Standard : (Specify) PEI RP 1200 <br /> r Engineered Method : (Specify) a-µ 3 <br /> f � ea � . tt <br /> Attach the testing procedures and all documentation required to determine the results . ,. oftE etd Pages <br /> _ � <br /> Tank ID : (By tank number, stored product, etc.) Fill T1 Fill T2 <br /> SUPREME REGULAR <br /> Spill Container Manufacturer: Franklin/EBW Franklin/EBW <br /> Non-Mettalic Non-Mettalic Non-Mettalic Non-Mettalic <br /> Method of Cathodic Protection r Isolation r Isolation r Isolation 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? r Yes r No F Yes r No r Yes r No r Yes r No <br /> W Drain Valve W 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 /> F 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 /> N. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results !" •Pass r Fail r!' Pass Fail rPass r Fail rPass F5 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 /> Vl. 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 /> X; <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 />