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UNDERGROUNDSTORAGETANK ' <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test Repair Test W 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10184299 2/7/2020 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> CHEVRON 209167 <br /> Business Site Address City: Zip. <br /> 1234 E. YOSEMITE AVE @ SPRECKLES MANTECA 95336 <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 /> 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 /> III, SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : F. Manufacturer Guidelines : (Specify) <br /> F' Industry Code or Engineering Standard : (Specify) PEI RP 1200 <br /> F Engineered Method : (Specify) <br /> # 0f Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results . <br /> Fill T:2 Fill T: 1 <br /> Tank ID: (By tank number, stored product, etc.) REGULAR SUPREME <br /> Spill Container Manufacturer: OPW OPW <br /> W Non-Metallic r' Non-Metallic Non-Metallic Non-Metallic <br /> L: <br /> Method of Cathodic Protection Isolation r Isolation Isolation r Isolation <br /> r Other r Other 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 EEVEEE <br /> Depth of Spill Container: ( Inches) 14 <br /> Does the spill container have a 5 gallon capacity ? rYes No r Yes r No Yes r No r Yes F No <br /> r Drain Valve r Drain Valve r Drain Valve F Drain Valve <br /> Method to Keep Spill Container Empty r Onsite Pump F Onsite Pump F Onsite Pump r Onsite Pump <br /> F Other F Other F Other F 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 I+ PaSS Fail ISP ass Fail �PBSS Fail _ � 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 /> UI. 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 /> ,AW jw <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached . <br /> ..rr, c�_ n _ rc.. .... : ., c ... .: .... .. ... o.,tol Rnnnrfinn Svwtpm - ID=Identification . UST=Underground storage tank, ICC=International Code Council <br />