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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM (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 /> 10181335 2/20/2020 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> CHEVRON # 94275 <br /> Business Site Address City: Zip: <br /> 2905 W. BENJAMIN HOLT @ I-5 STOCKTON 95207 <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 6/13/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> ICC - CA UST Service Technician 8361393 06/13/2021 Tanknology Certification - Level III Spill Container Testing Certification Exam 115240 <br /> 06/09/2022 <br /> Ill. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : r Manufacturer Guidelines : (Specify) <br /> I Industry Code or Engineering Standard : (Specify) PEI RP 1200 <br /> r Engineered Method : (Specify) <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results . <br /> Fill T2 Fill T1 Fill T3 <br /> Tank ID: (By tank number, stored product, etc.) REG UNLEAD SUPREME DIESEL2 <br /> Spill Container Manufacturer: Franklin/EBW Franklin/EBW Franklin/EBW <br /> r Non-Metallic r Non-Metallic W Non-Metallic Non-Metallic <br /> Method of Cathodic Protection Isolation r Isolation r Isolation r Isolation <br /> Other r Other r Other r 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) 12 12 12 <br /> Depth of Spill Container: (Inches) 13 13 13 <br /> Does the spill container have a 5 gallon capacity ? W Yes No Yes r No W Yes No r Yes r No <br /> Drain Valve r' Drain Valve WDrain Valve r Drain Valve <br /> Method to Keep Spill Container Empty r Onsite Pump r Onsite Pump r Onsite Pump r Onsite Pump <br /> r Other r Other r Other r 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 rPass r Fail RPass F; Fail WPass r Fail rPBSS Fail <br /> V. COMMENTS <br /> All items marked failed above must be explained in this section . Any additional comments may also be prop -r <br /> d ra f <br /> = FCS A 1 � 1` <br /> Uh CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> 1 hereby certify that the spill containers were tested in accordance with California Code of Regulations, YtIp s23; diGi ii n`` , ` gap er 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 /> F „,.rr^nma.,tar Rennrtina Svstem. ID=Identification, UST=Underground storage tank, ICC=International Code Council <br />