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UNDERGROUND STORAGE TANK <br />CERS = California Environmental Reporting System, ID =Identification, UST= Underground Storage Tank, ICC = International <br />SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br />Type of Action ❑ installation Test ❑ Repair Test Q 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Spill Container Test <br />3/8/2019 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Chevron <br />Business Site Address City <br />ZIP Code <br />6633 Pacific Av. Stockton Ca. <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 />Brian Roth <br />(916) 3824761 <br />Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />949066 8834817 10/19/2019 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />OPW <br />111. SPILL CONTAINER TESTING INFORMATION <br />Test Method Used: ❑ Manufacturer Guidelines (Specify): <br />El Industry Code or Engineering Standard (Specify): <br />5 Galion liquid measurement no drop for 1 HR <br />❑ Engineered Method (Specify): <br />Attach the testing procedures and all documentation required to determine the results. <br /># of Attached Pages <br />TANK ID: (By tank number, stored product, etc.)TNon�Metallic <br />7-1 <br />87-2 <br />Ep <br />91 <br />Spill Container Manufacturer: <br />PW <br />OPW <br />OPW <br />Method of Cathodic Protection: <br />❑x Non -Metallic <br />QNon-Metallic <br />❑ Non -Metallic <br />❑ Isolation <br />❑ Isolation <br />❑ Isolation <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V.) <br />❑ Other (Specify in V) <br />❑ Other (Specify in v) <br />Inside Diameter of Spill Container: (inches) <br />12" <br />12" <br />12" <br />Depth of Spill Container: (Inches) <br />11 <br />Does the spill container have a 5 gallon capacity? FAI Yes El No 9 Yes El No El Yes El No ❑ Yes E] No <br />Method to Keep Spill Container Empty: Z Drain Valve ❑x Drain Valve Q Drain Valve ❑ Drain Valve <br />❑ Onsite Pump ❑ Onsite Pump ❑ Onsite Pump El Onsite Pump <br />❑ Other (Specify in V) ❑ Other (Specify in V) ❑ Other (Specify in V.) ❑ Other (Specify in v.) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: 9 Pass ❑ Fail ❑x Pass ❑ Fail 9 Pass ❑ Fail ❑ Pass ❑ Fail <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 CONOUCTWWAS+`fyTIKG <br />I hereby certify that the spill containers were tested in accordance with California Code f Re616)atl6ths, Title 23, Division 3, <br />Chapter 16, Section 2637.1 and all the information contained herein is accurate. <br />UST Service Technician Signature <br />If the facility has mnra rmmnnnanlc /hen fh;� t ,..,, <br />Code Council <br />