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UNDERGROUNDSTORAGETANKi <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action 1 . E Installation Test Repair Test 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10186665 3/13/2020 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> CHEVRON 307709 <br /> Zip : <br /> Business Site Address City: <br /> 10858 TRINITY PKWY STOCKTON 95219 <br /> ll. 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 None 6/13/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> ICC - CA UST Service Technician None 06/13/2021 Tanknology Certification - Level III Spill Container Testing Certification Exam 115240 <br /> 06/09/2022 <br /> 111, SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : r Manufacturer Guidelines : (Specify) <br /> Industry Code or Engineering Standard : (Specify) PEI RP 1200 <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.) Fill T1 Fill T-2 Fill T-3 <br /> UNLEADED PREMIUM Diesel <br /> Spill Container Manufacturer: OPW OPW OPW <br /> W1 Non-Metallic r' Non- Metallic Non-Metallic Non-Metallic <br /> Method of Cathodic Protection r Isolation r Isolation Isolation Isolation <br /> r Other r Other 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 12 <br /> Depth of Spill Container: ( Inches) 15 15 15 <br /> Does the spill container have a 5 gallon capacity? r' Yes r No r' Yes r No r Yes r No r Yes r No <br /> r Drain Valve r Drain Valve r Drain Valve r Drain Valve <br /> Method to Keep Spill Container Empty r Onsite Pump r Onsite Pump r Onsite Pump r Onsite Pump <br /> F 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 /> N. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results r=Pass r Fail rpass Fail WPaSS r Fail F.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 /> 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 /> 4L <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, 113=Identification , UST=Underground storage tank, ICC=International Code Council <br />