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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 9 12 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Spill Container Test <br />10180899 <br />2/12/19 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />WILSON WAY CHEVRON <br />Business Site Address City <br />ZIP Code <br />437 N. WILSON WAY STOCKTOK CA <br />95205 <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 />EDWARD STEARNS 1 (209) 744-0112 <br />Contractor / Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />14-1760 Ex. 9/30/20 <br />8883080-UT <br />11/9/2020 <br />Spill Container Testing Training and Certifications (List applicable certifications.) <br />Franklin Fueling - EBW & Phil Tite #1009893708 Ex. 11/29/2020 <br />OPW #104-635 Ex. 3/14/2020 <br />III. SPILL CONTAINER TESTING INFORMAT O ` <br />Test Method Used: <br />Z Manufacturer Guidelines (Specify): LAKE TEST <br />❑ Industry Code or Engineering Standard (Specify): <br />1EAL1 <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.) <br />1-87rNon�Metalfic <br />Spill Container Manufacturer: <br />CNI <br />Method of Cathodic Protection: <br />0 Non-Metallic <br />❑ Non-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 />11 <br />11 <br />Depth of Spill Container: (Inches) <br />13 <br />13 <br />Does the spill container have a 5 gallon capacity? <br />❑x Yes ❑ No <br />R Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Method to Keep Spill Container Empty: <br />❑x Drain Valve <br />0 Drain Valve <br />❑ Drain Valve <br />❑ Drain Valve <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Onsite Pump <br />❑ Other (Specify in V) <br />❑ Other (Specifyin V.) <br />❑ Other (Specify in V) <br />❑ Other (Specify in V) <br />IV. SUMMARY OF TESTING RESULTS <br />Spill Container Test Results: <br />❑Q Pass ❑ Fail 9 Pass ❑Fail <br />❑ Pass ❑ Fail <br />❑ 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 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 16, Section 2637.1 and all the information contained herein is accurate. <br />UST Service Technician Signature <br />7a <br />If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br />CERS = California Environmental Reporting System, ID =Identification, UST= Underground Storage Tank, ICC = International Code Council <br />