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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page i 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 /> 10785304 3/3/2020 <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 /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the iCC Celcation.) Phone # <br /> Curtis Carpenter (916) 372- 1885 <br /> Contractor I Tank Tester License # iCC Certification # ICC Certification Expiration Date <br /> 617238 8167865 5/13/2020 <br /> Spill Container Testing Training and Certifications (List applicable certificatlons.) <br /> OPW, Phil-Tate <br /> Ilia 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 aft documentation required to determine the results. # of Attached Pages <br /> TANK ID: (By tank number, stored product, etc.) 1 -87 2-91 3=Diesel <br /> Spill Container Manufacturer: OPW OPW OPW <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic p NorWatallic ❑ Non=Metallic <br /> ❑x Isolation ❑x isolation I] Isolation ❑ Isolation <br /> ❑ Other (Specify in V.) ❑ Other (Specify in v.) ❑ Other (Specify in V.) ❑ Other (Specifyin V.) <br /> Inside Diameter of Spill Container: (Inches) 1 1 .5 11 .5 11 . 5 <br /> Depth of Spill Container. (Inches) 12 .5 12 .5 12 . 5 <br /> Does the spill container have a 5 gallon capacity? I] Yes ❑ No I] Yes ❑ No 91 Yes ❑ No ❑ Yes ❑ No <br /> Method to Keep Spill Container Empty: ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve ❑ Drain Valve <br /> Onsite Pump ❑x Onsite Pump Q Onsite Pump ❑ Onsite Pump <br /> ❑ Other (Specifyin V.) ❑ Other (specify in v.) ❑ Other (Specify Inv) ❑ Other (specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: Q Pass ❑ Fail p Pass [:1 Fall 9 Pass ❑ Fall [I Pass ❑ Fail <br /> V. COMMENTS <br /> Any Items marked `Fall" above must be explained in this section. Any additional comments may also be provided here. <br /> i <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations, Title 23, Division 3, <br /> Chapter 18, Section 2637.1 and all the Information contained herein is accurate. <br /> UST Service Technician Signature , <br /> N the facility has more components than this form accommodates, additlonal copies of this page may be attached. <br /> CERS = Ca%x da Ernfton rental Reporting System, iD = ldentifxation, UST= Undepround Storage Tank, ICC = International Code Courd <br />�, L <br />