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UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Test ❑ Repair Test ❑Q 12 Month Test L FACILITY INFORMATION CERS ID Date of Spill Container Test 10180605 5/20/2020 Business Name (Same as Facility Name or DBA-Doing Business As) FLAG CITY CHEVRON Business Site Address City ZIP Code 6421 CAPITOL AVE LODI , CA 95242 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # ZANE NIMMO ( 209 ) 744 - 0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 04 - 1676 Ex . 3/31 /22 8883064 - UT 6/ 1 /2021 Spill Container Testing Training and Certifications (List applicable certifications.) Franklin Fueling - EBW & Phil Tite # 10009843708 Ex . 11 /29/2020 OPW # 104- 632 Ex . 3/ 15/2022 III . SPILL CONTAINER TESTING INFORMATION Test Method Used : ❑x Manufacturer Guidelines (Specify) : O P W PHASE I LAKE TESTING ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the testing procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, storedproduct, etc.) 91 OCTANE 87 OCTANE 87 SLAVE DIESEL Spill Container Manufacturer: O P W O P W O P W O P W Method of Cathodic Protection: ❑x Non- Metallic N Non-Metallic Z Non-Metallic Z Non-Metallic ❑ Isolation ❑ Isolation ❑ Isolation ❑ Isolation ❑ Other (Specifyin V.) ❑ Other (Specifyin V) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) Inside Diameter of Spill Container: (Inches) 11 1 /2 11 1 /2 11 1 /2 11 1 /2 Depth of Spill Container: (Inches) 12 1 /4 14 1 /2 14 1 /2 14 1 /2 Does the spill container have a 5 gallon capacity? R Yes ❑ No ❑X Yes ❑ No ❑x Yes ❑ No R Yes ❑ No Method to Keep Spill Container Empty: ❑x Drain Valve N Drain Valve ❑x Drain Valve ❑x Drain Valve ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Other (Specifyin V) I ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) ❑ Other (Specifyin V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results : TFZ Pass E] Fail ❑x Pass E] Fail ❑_ Pass ❑ Fail ❑x Pass ❑ Fail V. COMMENTS Any items marked "Fail" above must be explained in this section. Any additional comments may also be provided here. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations , Title 23 , Division 3 , Chapter 16 , Section 2637 . 1 and all the information contained herein is accurate . UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council