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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) <br /> Type of Action ®Installation Test ❑Repair Test ❑ 12 Month T <br /> 1.. FACILITY INFORMATION <br /> CERS ID Date of Spill Container Test <br /> 10181653 110125/19 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Chevron 201761 <br /> Business Site Address City ZIP Code <br /> 1103 S. Main Street Manteca 195337 <br /> H. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> Raymond Simms (916) 646 - 9680 Ext. <br /> ContractorTFank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 8258900 1612512020 <br /> Spill Container Testing Training and Certifications(List applicable cerlifrcations.) <br /> OPW <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: <br /> ❑Manufacturer Guidelines:(Specify) <br /> ® Industry Code or Engineering Standard:(Specify) LG 166 <br /> ❑Engineered Method:(Specify) <br /> #of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> Tank ID: (By tank number,stored product,etc.) 91 87-1 87-2 <br /> Spill Container Manufacturer: OPW OPW <br /> ❑Non-Metallic ❑ Non-Metallic ❑Non-Metallic El Non-Metallic <br /> Method of Cathodic Protection ® Isolation ® Isolation ® Isolation 0 Isolation <br /> ❑Other ❑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 finches) 16 16 16 <br /> Does the spill container have a 5 gallon capacity? ID Yes ❑No ®Yes ❑No E Yes ❑ No ❑Yes ❑No <br /> ®Drain Valve ®Drain Valve ®Drain Valve ❑ Drain Valve <br /> Method to Keep Spill Container Empty ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other ❑Other ❑Other ❑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 ® Pass ❑Fail ® Pass ❑Fail ®Pass ❑ Fail ❑Pass ❑Fail <br /> V. COMMENTS <br /> All items marked"FaiF 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 /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations,title 23,division 3,chapter 16,section <br /> 2837.1 and II the informs ' n contained herein is accurate. <br /> .UST ech ' ' n S- nature <br /> ityh6irrhore components than this form accommodates,additional copies of this page may be attached <br /> CERS=California Emrinrnental Reporting System,D=Identification,UST=Underground sk rage tank ICC=Snilenaiional-Code oundl <br />