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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 />UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Test ❑ Repair Test ❑Q 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />10181345 <br />Date of Spill Container Test <br />10/24/18 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />CHARTER WAY CHEVRON <br />Business Site Address City ZIP Code <br />508 CHARTER WAY STOCKTOR CA 95296 <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 />Felix Ramirez (209) 744-0112 <br />Contractor / Tank Tester License # <br />08-1740 5-31-20 <br />ICC Certification # <br />8883072 -UT <br />ICC Certification Expiration Date <br />11/22/2018 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tite #1009883708 11-16-18 <br />OPW #104634 3-14-20 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: <br />❑x Manufacturer Guidelines (Specify): OpW Water/ tape <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the testing procedures and all documentation required to determine the results. <br /># of Attached Pages <br />TANK ID: (By tank number, stored product, etc.) <br />87A <br />87 - B <br />91 <br />Spill Container Manufacturer: <br />OPW <br />OPW <br />OPW <br />Method of Cathodic Protection: <br />0 Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in v.) <br />❑x Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V) <br />❑x Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />Inside Diameter of Spill Container: (Inches) <br />11 <br />11 <br />11 <br />Depth of Spill Container: (Inches) <br />14 <br />14 <br />14 <br />Does the spill container have a 5 gallon capacity? <br />0 Yes ❑ No <br />❑x Yes ❑ No <br />F1 Yes ❑ No <br />❑ Yes ❑ No <br />Method to Keep Spill Container Empty: <br />0 Drain Valve[g] <br />❑ Onsite Pump <br />❑ Other (Specify in V.)❑ <br />Drain Valve <br />❑ Onsite Pump <br />Other (Specify in V.) <br />0 Drain Valve <br />❑ Onsite Pump <br />ElOther (Specify in V.) <br />❑ Drain Valve <br />❑ Onsite Pump <br />ElOther (Specify in V.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: <br />❑X Pass ❑ Fail ❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ 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�� <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 />