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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month X 36 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10184725 4/15/2022 <br /> Facility Name <br /> Chevron <br /> Facility Address City ZIP Code <br /> 2615 Grantline Road Tracy 95304 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Pinnacle Fuel Compliance 408=206=9840 <br /> Mailing Address <br /> P . O . Box 32849 <br /> Service Technician Performing Test <br /> Aneil Chand <br /> Contractor/Tank Tester License Number <br /> SWRCB 90- 1262 <br /> ICC Number ICC Expiration Date <br /> 8455316 5/27/2022 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> NOV 2/18/2024 <br /> Caldwell Level Change indicator 2/28/2024 <br /> SWRCB Tank Testing License #90 = 1262 3/31 /2023 <br /> ICC Technician , Installer , Operator Cert# 8455316 5/27/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic / time Piping sumps , under dispenser sumps <br /> Vacuum / time Tank dry annulars / secondary containment <br /> Pressure / time product , vapor, vent secondary piping <br /> 5 . CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the secondary containment was tested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637; that required supporting documentation is <br /> attached; and all information contained herein is accurate. I understand that test procedures shall be <br /> made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> } 4/15/2022 7 <br /> 6 . TANK SECONDARY CONTAINMENT TEST <br /> CERS = California Environmental Reporting System , ICC = International Code Council , <br /> ID = Identification , NA = Not Applicable , UDC = Under- Dispenser Containment , <br /> Page 1 of 5 <br />