Laserfiche WebLink
UNDERGROUNDSTORAGETANK' <br /> SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1 ) <br /> Type of Action r Installation Test Repair Test ' 12 Month Test <br /> I. FACILITYINFORMATION <br /> CERS ID Date of Spill Container Test: <br /> 10182313 2/7/2019 <br /> Business Name (Same as Facility Name or DBA- Doing Business As . ) <br /> CHEVRON #208117 <br /> Business Site Address City: Zip : <br /> 755 S . TRACY BLVD TRACY 95376 <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 /> Jesus Saldivar (800 ) 800-4633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8361393 6/ 16/2019 <br /> Spill Container Testing Training and Certifications (List applicable certifications.) <br /> ICC - CA UST Service Technician 8361393 06/16/2019 Tanknology Certification - Level III Spill Container Testing Certification Exam 115240 <br /> 07/06/2019 <br /> 111. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used : r= Manufacturer Guidelines : (Specify) <br /> Industry Code or Engineering Standard : (Specify) PEI RP 1200 <br /> Engineered Method : (Specify) <br /> Attach the testing procedures and all documentation required to determine the results . # of Attached Pages <br /> Tank ID : (By tank number, stored product, etc.) Fill T 2 Fill T 1 <br /> REGULAR PREMIUM <br /> Spill Container Manufacturer: OPW OPW <br /> r Non-Mettalic ry Non-Mettalic Non-Mettalic r Non- Mettalic <br /> Method of Cathodic Protection Isolation r Isolation r Isolation Isolation <br /> Other r Other r 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) 14 14 <br /> Depth of Spill Container: ( Inches) 15 15 <br /> Does the spill container have a 5 gallon capacity? r Yes r No r Yes r No r Yes r No r Yes r No <br /> F Drain Valve Drain Valve r Drain Valve Drain Valve <br /> Method to Keep Spill Container Empty r Onsite Pump Onsite Pump r Onsite Pump r Onsite Pump <br /> r Other r Other r Other r 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 FPaSS r Fail WPass r Fail rPaSS r Fail FPass r Fail <br /> V. COMMENTS <br /> All items marked failed above must be explained in this section . Any additional comments may also be provided here . <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <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 all the information contained herein is accurate . <br /> UST Service Technician Signature <br /> I If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> i <br /> CERS=California Environmental Reporting System, ID=Identification , UST= Underground storage tank, ICC=International Code Council <br />