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UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action E Installation Test [2] Repair Test 0 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />10181341 <br />Date of Spill Container Test <br />11/20/2018 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Chevron 99840 <br />Business Site Address <br />4344 Waterloo Rd <br />City <br />Stockton <br />ZIP Code <br />95215 <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 />Nick Harvey <br />Phone # <br />(916) 834-5099 <br />Contractor / Tank Tester License # <br />300345 A B C61/D40 HAZ <br />ICC Certification # <br />5115738 <br />ICC Certification Expiration Date <br />2/13/2019 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Philtite <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: CI Manufacturer Guidelines (Specify): <br />0 Industry Code or Engineering Standard (Specify) PEI RP1200 <br />0 Engineered Method (Specify): <br />Attach the testing procedures and all documentation required to determine the results. <br />II of Attached Pages <br />TANK ID: (By tank number, stored product, etc.) 87 Fill 87 Vapor 91 Fill 91 Vapor <br />Spill Container Manufacturer: Philtite Philtite Philtite Philtite <br />Method of Cathodic Protection: El Non-Metallic <br />El Isolation <br />[1] Other (Specify in V.) <br />0 Non-Metallic <br />E Isolation <br />E Other (Specify in V.) <br />0 Non-Metallic <br />CI Isolation <br />CI Other (Specify in V.) <br />0 Non-Metallic <br />Li Isolation <br />n Other (Specify in V.) <br />Inside Diameter of Spill Container: (Inches) 12" 12" 12" 12" <br />Depth of Spill Container: (Inches) 14" 14" 14" 14" <br />Does the spill container have a 5 gallon capacity? El Yes 0 No 0 Yes CI No E Yes CI No E Yes El No <br />Method to Keep Spill Container Empty: El Drain Valve <br />CI Onsite Pump <br />E Other (Specify in V.) <br />0 Drain Valve <br />lil Onsite Pump <br />CI Other (Specify in V.) <br />0 Drain Valve <br />CI Onsite Pump <br />0 Other (Specify in V.) <br />E Drain Valve <br />ii Onsite Pump <br />0 Other (Specify in V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: 0 Pass 0 Fail II] Pass CI Fail X Pass 0 Fail CI Pass 0 Fail <br />V. COMMENTS <br />Any items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br />I hereby certify that the spill containers were tested in accordance with California Code of Regulations, Title 23, Division 3, <br />Chapter 16, Section 2637.1 and all the information contained herein is accurate. <br />UST Service Technician Signature 10 iL,\ <br />Z I <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