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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FOR (Page 1 of 1) <br /> Type of Action ❑Installation Test ❑Repair Test ❑12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181653 11/7/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Chevron 201761 <br /> Business Site Address City ZIP Code <br /> 1103 S Main Street Manteca 95337 <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 /> Nick Harvey (916) 834 -5099 Ext. <br /> Contractors rank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 300345 A B C61/D40 HAZ 5115738 02/13/2019 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑Manufacturer Guidelines:(Specify) <br /> E Industry Code or Engineering Standard:(Specify) PEI RP1200 <br /> ❑Engineered Method:(Specify) <br /> #of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> Tank ID:(By tank number,stored product,etc.) 87-1 Fill 87-1 Vapor 87-2 Fill 87-2 Vapor <br /> Spill Container Manufacturer: Philtite Philtite Philtite Philtite <br /> E Non-Metallic E Non-Metallic E Non-Metallic E Non-Metallic <br /> Method of Cathodic Protection ❑ Isolation ❑ Isolation ❑Isolation ❑Isolation <br /> ❑Other ❑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:(Inches) <br /> 12" 12" 12" 12" <br /> Depth of Spill Container:(Inches) 12.5" 12.5" 12.5" 12.5" <br /> Does the spill container have a 5 gallon capacity? E Yes ❑No E Yes ❑No E Yes ❑No ®Yes ❑No <br /> E Drain Valve ❑Drain Valve E Drain Valve ❑Drain Valve <br /> Method to Keep Spill Container Empty ❑Onsite Pump E Onsite Pump ❑Onsite Pump ®Onsite Pump <br /> ❑Other ❑Other ❑Other ❑Other <br /> (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ❑Pass EFail E Pass ❑Fail I ❑Pass E Fail 11 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 /> *87-1 & 87-2 Fill buckets failed bad drain assembly/o-ring <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,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 />