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Received by EHD: <br /> 1/9/2023 Appendix VII <br /> via e-mail <br /> Underground Storage Tank <br /> Secondary Containment Testing Repoli Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month ® 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181667 2!3122 <br /> Facility Name <br /> Chevron 201383 <br /> Facility Address City ZIP Code <br /> 1960 W Eleventh Street Tracy 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Wayne Perry, Inc. 774826-0352 <br /> Mailing Address <br /> 8281 Commonwealth Avenue,.Buena Park CA 90621 <br /> Service Technician Performing Test <br /> Nick Harvey _ <br /> Contractor/Tank Tester License Number <br /> 300345 A B C611D40 HAZ <br /> ICC Number ICC Expiration Date <br /> 5115738 12/3/2022 <br /> .3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Incon Level 4 7128/23 <br /> Bravo SWAT#2019-2929491 411212022 <br /> Xerxes #11911 1212712024 <br /> NOV 412612024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI RP1200 Annulars <br /> PEI RP1200 Secondary Lines <br /> PEI RP1200 UDC`s <br /> PEI RP1200 Sumps <br /> 5. CERTIFICATION BY:SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature „j 1 4 Date Total #of Pages <br /> 213122 <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 />