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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORA (Page 1 of 1 ) <br /> Type of Action ® Installation Test ❑ Repair Test ❑ 12 Month T4 <br /> I . FACILITY INFORMATiON <br /> CERS ID Date of Spill Container Test <br /> 1018 / 653 10/25/19 <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 95337 <br /> 11. 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 /> ContractorfFank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 8258900 6/25/2020 <br /> Spill Container Testing Training and Certifications (List applicable certifications) <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 87A 87'2 <br /> Spill Container Manufacturer. OPW OPW <br /> ❑ Non-Metallic ❑ Non-Metallic ❑ NonWetallic ❑ Non-Metallic <br /> Method of Cathodic Protection ® isolation ® Isolation 0 Isolation ❑ 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) T12 12 12 <br /> Depth of Spill Container. (inches) 16 16 16 <br /> Does the spill container have a 5 gallon capacity? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ NorCEI] Yes ❑ No <br /> ® Drain Valve ® Drain Valve ® Drain Valve 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 /> 1V. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> All 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 /> 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 li the informs ' n contained herein is accurate. <br /> .UST ech ' '4rn "nature <br /> ity ore components than this form accommodates, additional copies of this page may be attached. <br /> CERS Caldbmia Environmental Reporting System, to = klsntificatlor , UST = Undergroundstordgetk, ICC = 6ilerrationalCodeCouncil <br />