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UNDERGROUNDSTORAGETANKi <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test Repair Test 12 Month Test <br /> L FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10184539 1 /17/2019 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> CHEVRON 210997 ( W4693) <br /> Business Site Address City: Zip : <br /> 1442A COLONY DR, RIPON 95366 <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 /> Jesus Saldivar (800) 800-4633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8361393 6/ 16/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> ICC - CA UST Service Technician 8361393 06/16/2019 Tanknology Certification - Level III Spill Container Testing Certification Exam 115240 <br /> 07/06/2019 <br /> III. SPILL CONTAINER TESTING INFORMATiONx< = t <br /> Test Method Used : Manufacturer Guidelines : (Specify) <br /> W Industry Code or Engineering Standard : (Specify) PEI RP 1200 PER <br /> Engineered Method : (Specify) <br /> # of Atta -h I-Pages <br /> Attach the testing procedures and all documentation required to determine the results . <br /> Tank ID: (By tank number, stored Fill T1 : SUPREME Fill T2 : REGULAR <br /> product, etc.) UNLEADED UNLEADED <br /> PREMIUM REGULAR <br /> Spill Container Manufacturer: OPW OPW <br /> Non-Mettalic Non-Mettalic Non-Mettalic r Non-Mettalic <br /> Method of Cathodic Protection Isolation r Isolation Isolation Isolation <br /> Other r Other Other Other <br /> (Specify in section V) (Specify in section V) (Specify in section V) (Specify in section V) <br /> Inside Diameter of Spill Container: 14 14 <br /> ( Inches ) <br /> Depth of Spill Container: ( Inches) 11 11 <br /> E Does the spill container have a 5 Yes r No rv,' Yes r No r Yes r No r Yes No <br /> I gallon capacity? <br /> 1 Drain Valve Drain Valve r Drain Valve r Drain Valve <br /> Method to Keep Spill Container Onsite Pump Onsite Pump r Onsite Pump Onsite Pump <br /> E <br />( Empty Other Other r Other 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 WPass � r Fail Pass F Fail ( Pass F ! : <br /> Fail Pass F, 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 /> V1. 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 3, chapter 16 , section <br /> 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 />