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EG ED <br /> f UNDERGROUND STORAGE TANK <br /> f 5 ILL CONTAINER TESTING REPORT FORM(Page 1 of 1) <br /> Type of Action ❑Ins all��r Test El Repair Test 5d12 Month Test <br /> ENVIR I. FACILITY INFORMATION <br /> CERS ib--- M_j�EPAR _NT Date of Spill Container Test <br /> 10184563 06/20/19 -_- <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Chevron <br /> Business Site Address City ZIP Code <br /> 3400 N.MacArthur Tracy 95376 <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 /> Steve Parmenter 4089712445 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8818846-UT 2124121 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> 100263708/100604 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ®Manufacturer Guidelines(Specify): OPW <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) 1 Prem 2 Regular 3 Diesel 4 <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: 0 Non-Metallic V)Non-Metallic 0 Non-Metallic ❑Non-Metallic <br /> ❑Isolation ❑Isolation ❑Isolation ❑Isolation <br /> ❑Other(specify in v.) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container:(Inches) 16 16 16 <br /> Depth of Spill Container:(inches) 16 16 16 <br /> Does the spill container have a 5 gallon capacity? ©Yes ❑No ©Yes ❑No ©Yes ❑No ❑Yes ❑No <br /> Method to Keep Spill Container Empty: ®Drain Valve ❑Drain Valve ®Drain Valve ❑Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in V.) F ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results ❑Pass 0 Fail Pass ❑Fail {a Pass ❑Fail ❑Pass ❑Fail <br /> V. COMMENTS <br /> Any items marked"Fail"above must be explained in this section. Any additional comments may also be provided here. <br /> 91 Fill Bucket Failed due to manufacturer defect. Installing Contractor will fix. <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, <br /> Chapter 16,Section 2637.1 and all the information contained herein is accurate. <br /> UST Service Technician Signature �w <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 />