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AppendixVII <br /> Underground Storage Tank received 04/28/2022pn. <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month M 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 1018139 5-11-2021 <br /> Facility Name <br /> MANTECA CHEVRON <br /> Facility Address City ZIP Code <br /> 1257 WEST YOSEMITE MANTECA CA 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> FRANZEN-HILL 559-688-2977 <br /> Mailing Address <br /> 1100 N J ST TULARE CA. 93274 <br /> Service Technician Performing Test <br /> DAVID TURNER <br /> Contractor/Tank Tester License Number <br /> A304147 <br /> ICC Number ICC Expiration Date <br /> 8788650-UT <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> STPINCON STS 1-19-22 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> HYDRO STATIC 87 STP, 87FILL,91STP,91 FILL,DSL STP,DSL FILLSUMPS <br /> UDCS 1/2,3/4,5/6,7/8 <br /> 5 psi secondaryline 87,91,dsi,aux dsl <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the secondary containment was tested in accordance with California <br /> Code of Regulations, title 23, division 3, chapter 16, section 2637; that required supporting <br /> documentation is attached; and all information contained herein is accurate. / understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <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 />