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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> toot Type of Action ❑ Installation Test ❑ Repair Test 9 12 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Dale of Spill Container Test <br /> 10785304 3!312020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> AGS DBA Chevron <br /> Business Site Address City ZIP Code <br /> 1490 South Main Street Manteca 195337 <br /> OWN II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Pint as shown on the ICC Certification.) Phone # <br /> Curtis Carpenter (916) 372- 1885 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 617238 8167865 5/13/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> OPW, Phil-rite <br /> Ill. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: x❑ Manufacturer Guidelines (Specify): <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 =87 2-91 3= DieSei <br /> Spill Container Manufacturer. OPW OPW OPW <br /> aw <br /> Method of Cathodic Protection: ❑x Non4etallic ❑x Non-Metallic ❑x Non-Metallic FNon=Metalfic <br /> D Isolation x❑ Isolation Isolation <br /> ❑ Other (specify in v.) ❑ Other (Specify in V.) ❑ Other (SpecNy in V.) ❑ Other (specify in v.) <br /> Inside Diameter of Spill Container: (Inches) 11 . 5 11 . 5 1 1 . 5 <br /> Depth of Spill Container: (Inches) 12 ,5 12 , 5 12 , 5 <br /> Does the spill container have a 5 gallon capacity? 91 Yes ❑ No 2 Yes ❑ No 91 Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> p Onsite Pump Q Onsite Pump ❑x Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specify Inv.) 1 ❑ Other (Specifyin v.) ❑ Other (Specify in v.) ❑ Other (Specify In V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑x Pass ❑ Fall ❑x Pass ❑ Fail Pass ❑ Fail [:] Pass ❑ Fall <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. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING 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 /> l <br /> ff the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = CaBfomia Environmental Reporting System, ID = Iderdication, UST= Underground Storage Tank, iCC = Intemallonal Code Council <br /> I <br /> f <br /> i <br />