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UNDERGROUND STORAGE TANK <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Test ❑ Repair Test X 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID Date of Spill Container Test <br />10181469 5/4/2020 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />TONY — COLLIER ROAD CHEVRON <br />Business Site Address PAMPO,CA <br />ZIP Code <br />25651 N. HIGHWAY 99 95220 <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 />ZANE NIMMO (209) 744-0112 <br />Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />04-1676 Ex. 3/31/22 8883064—UT 6/1/2021 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tite #10009843708 Ex. 11/29/2020 <br />OPW #104-632 Ex. 3/14/2020 <br />III. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: 9 Manufacturer Guidelines (Specify): PHIL TITE PHASE 1 LAKE TESTING <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the testing procedures and all documentation required to determine the results. # of Attached Pages <br />TANK ID: (By tank number, stored product, etc.) <br />Spill Container Manufacturer: <br />Method of Cathodic Protection: <br />Inside Diameter of Spill Container: (Inches) <br />Depth of Spill Container: (Inches) <br />Does the spill container have a 5 gallon capacity? <br />Method to Keep Spill Container Empty: <br />U <br />Spill Container Test Results: <br />1 — DSL <br />PHIL TITE <br />❑x Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V) <br />12 <br />15 <br />0 Yes ❑ No <br />2 — 91 OCT <br />PHIL TITE <br />N Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />12 <br />14 1/2 <br />Q Yes ❑ No <br />❑x Drain Valve ❑x Drain Valve <br />❑ Onsite Pump ❑ Onsite Pump <br />❑ Other (Specify in V.) ❑ Other (Specify in V.) <br />SUMMARY OF TESTING RESULTS <br />Zx Pass ❑ Fail 11 ❑x Pass ❑ Fail I <br />3-87 OCT <br />PHIL TITE <br />❑x Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />12 <br />14 1/4 <br />F] Yes ❑ No <br />Zx Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V.) <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑ Yes ❑ No <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Other (Specify in V) <br />❑x Pass ❑ Fail 11 ❑ Pass ❑ Fail <br />V. COMMENTS <br />Any items marked "Fail' above must be explained in this section. Any additional comments may also be provided he Le. <br />NED <br />uMAY 12 2020 <br />'_NTAL % EALn , <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING'.117NT <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 />f the facility has more comnonents than this form accommodates_ additional conies of this naoe may <br />CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />