Laserfiche WebLink
Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br /> <br />Page 1 of 2 <br />TYPE OF ACTION ☐ Installation ☐ Repair ☒ 12 Month <br />1. FACILITY INFORMATION <br /> <br />CERS ID <br />10397599 <br />Test Date <br />11/18/21 <br /> <br />Facility Name <br />Sutter Tracy Community Hospital <br /> <br />Facility Address <br />1420 N. Tracy Blvd. <br />City <br />Tracy <br />ZIP Code <br />95376 <br /> <br />2. SERVICE TECHNICIAN INFORMATION <br /> <br />Company Performing the Test <br />Alltech Petro, Inc <br />Phone <br />209-532-7320 <br /> <br />Mailing Address <br />P.O. Box 4208 Sonora Ca, 95370 <br />Service Technician Performing Test <br />Isaac Anderson <br />Contractor/Tank Tester License Number <br />CA 623541/09-1749 <br /> <br />ICC Number <br />8146912 <br />ICC Expiration Date <br />09/10/22 <br /> <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />OPW #100456 05/11/22 <br /> <br /> <br /> <br />4. TEST PROCEDURE INFORMATION <br /> <br />Test Procedures Used Components Tested <br />PEI RP 1200/Manufacturer Red Diesel Fill Spill Bucket <br /> <br /> <br /> <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />/I hereby certify that each spill container was tested in accordance with California Code of <br />Regulations, title 23, division 3, chapter 16, section 2637.1; that required supporting <br />documentation is attached; and all information contained herein is accurate. I understand <br />that test procedures shall be made available upon request by the governing authority. <br /> <br />Service Technician Signature Date <br />11/18/21 <br />Total # of Pages <br />2 <br />