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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 /> 10443520 4/9/2019 <br /> Business Name (Same as Facility Name or DBA -Doing Business As) <br /> THORNTION CHEVRON <br /> Business Site Address City ZIP Code <br /> 9015 WALNUT GROVE RD THORNTON 95686 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # <br /> FELIX RAMIREZ ( 209 ) 744 -0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08- 1740 5-31 -20 8883072 - UT 11 /9/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> Franklin Fueling - EBW & Phil Tite # 1009883708 11 /29/20 <br /> OPW # 104634 3- 14-20 <br /> III . SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : Zx Manufacturer Guidelines (Specify) : LAKE TEST <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify) : <br /> # <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.) 87 91 DIESEL <br /> Spill Container Manufacturer: PHIL TITE PHIL TITE PHIL TITE <br /> Method of Cathodic Protection: ❑x Non-Metallic Zx Non-Metallic ❑x 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) 11 11 1 11 <br /> Depth of Spill Container: (Inches) 14 14 14 <br /> Does the spill container have a 5 gallon capacity? R Yes ❑ No ❑ Yes ❑x No ❑ Yes EINo ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: Zx Drain Valve ❑x Drain Valve Zx Drain Valve ❑ Drain Valve <br /> ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify in v) ❑ Other (Specify in V.) ❑ Other (Specify in v.) ❑ Other (Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: R Pass ❑ Fail ❑x Pass ❑ Fail ❑x 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 /> vi AY 2 1 2020 <br /> t rt ,+TAI ALTH <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN C UCTING THIS TESTING <br /> 1 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 /> If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = Califomia Environmental Reporting System, ID = Identification , UST = Underground Storage Tank, ICC = Intemational Code Council <br />