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w <br /> 4 <br /> UNDERGROUND STORAGE TANK <br /> SPILL: CONTAINER TESTING , REPORT FORM {Page 1 of 1 ) <br /> III lip <br /> Type of Action EI Installation Test ❑ Repair Test — ® 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test i <br /> 10181329 420-2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> MANTECA CHEVRON <br /> Business Site Address City ZIP Code <br /> 1257 WEST YOSEMITE MANTECA 95337 <br /> II , UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION . . <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Cortilication.) Phone # _ <br /> DAVID MARTIN (559) 688 - 2977 Ext. <br /> Contractor/Tank Tester License # E52416124 <br /> ertification # ICC Certification Expiration Date <br /> A304147 7 9- 16-2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> PHIL TITE VR101 1022923708 EXP. IBA2-2020 <br /> IIi. ' SPiLL CONTAINER TESTING INFORMATION <br /> Test Method Used: __.__..,._.__ ..._.._._. ._.._.r. -- <br /> 0 Manufacturer Guidelines: (Specify) HYDROSTATIC <br /> E) Industry Code or Engineering Standard: (Specify) <br /> 0 Engineered Method: (Specify) <br /> Attach the testis # of Attached Pages — I <br /> q procedures and all documentation required to determine the results. , <br /> . . . . . . <br /> Tank ID: (By tank number, stored product, etc.) UNLEADED PREMIUM DIESEL <br /> Spill Container Manufacturer: PHIL TITE PHIL TITE PHIL TITE <br /> ® Non•MetallIC ® Non•Metallic 0 Non-Metallic n Non-Metallic <br /> Method of Cathodic Protection 0 Isolation E) Isolation EI Isolation E] Isolation <br /> 0 Other E] Other E] Other 0 Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (specify in section V.) <br /> Inside Diameter of Spilt Container: (inches) 12a� 12s - 12 = <br /> Depth of Spill Container: (Inches) 16 16 16 <br /> Does the spill container have a 5 gallon capacity? ® Yes EI No 10 Yes O No 10 Yes E) No E] Yes ❑ No <br /> 0 Drain Valve ® Drain Valve ® Drain Valve ❑ Drain Valve <br /> i <br /> Method to Keep Spill Container Empty ❑ Onsite Pump Ea Onsite Pump 0 Onsite Pump E1 Onsite Pump <br /> ❑ Other ❑ Other Q Other E] Other <br /> (spedy in section V.) (Specify in section V) I (specify in section V) (Specify in section V.) <br /> _ <br /> IV* SUMMARY OF TESTING RESULTS - <br /> _ Spill Container Test Results Y — _ 0 Pass 0 Fail EI Pass 0 Fail ❑ Pass ® Fail E] Pass ❑ Fail <br /> V. COMMENTS <br /> All items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. <br /> DRAIN VALVES FAILED TO HOLD LIQUID <br /> - VI . . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THiS TESTING <br /> I hereby certify that the spill containers were to tell in accordance with California Code of Regulations, title 23, division 3, chapter 16, section <br /> 2637. 1 and att.t a Informptidii conta'ned her�er,"fti is accurate, <br /> UST Services echnic'a Signa ,fe` <br /> s✓i" <br /> E <br /> I <br />