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UNDERGROUNDSTORAGETANK <br /> SPILL CONTAINER TESTING REPORT FORM(Page 1 of 1) <br /> Type of Action F Installation Test r Repair Test r 12 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10182313 7 2/6/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> CHEVRON#208117 <br /> Business Site Address City: Zip: <br /> 755 S.TRACY BLVD 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 /> Brent Bowen (800)800-4633 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Class A General Engineering 743160 8211862 6/17/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> CA-Tightness Testing 14-1759 06/30/2020 ICC-ICC UST Tank Tightness Testing ICC000217688 06/17/2021 <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: r Manufacturer Guidelines: (Specify) <br /> IO Industry Code or Engineering Standard: (Specify) PEI RP 1200 <br /> F 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.) Fill T 1 Fill T 2 <br /> PREMIUM REGULAR <br /> Spill Container Manufacturer: OPW OPW <br /> W Non-Metallic F-0 Non-Metallic r Non-Metallic [- Non-Metallic <br /> Method of Cathodic Protection [- Isolation [- Isolation r Isolation [- Isolation <br /> F Other r Other r Other [- 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 <br /> Depth of Spill Container: (Inches) 14 14 <br /> Does the spill container have a 5 gallon capacity? r Yes [- No r Yes [- No r Yes [- No [-Yes [- No <br /> F Drain Valve r Drain Valve r Drain Valve [- Drain Valve <br /> Method to Keep Spill Container Empty r Onsite Pump [- Onsite Pump r Onsite Pump r Onsite Pump <br /> [- Other [- Other r Other r Other <br /> Specify in section V) (Specify in section V) (Specify in section V) (Specify in section V) <br /> N. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results 1-Pass r Fail Pass r Fail F—Pass r Fail [—Pass r Fail <br /> V. COMMENTS <br /> All items marked failed above must be explained in this section. Any additional comments may also be provided here. <br /> Changed drain on 87 spill bucket. Restarted test buckets pass. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations,title 23,division 3,chapter 16,section <br /> 2637.1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> ��/ <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Califomia Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council <br />