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COMPLIANCE INFO_2023
EnvironmentalHealth
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2300 - Underground Storage Tank Program
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PR0231861
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COMPLIANCE INFO_2023
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Last modified
10/4/2023 3:42:32 PM
Creation date
3/21/2023 1:56:00 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2023
RECORD_ID
PR0231861
PE
2361
FACILITY_ID
FA0003601
FACILITY_NAME
ARCO STATION #826951*
STREET_NUMBER
130
Direction
S
STREET_NAME
WILSON
STREET_TYPE
WAY
City
STOCKTON
Zip
95205
APN
15502064
CURRENT_STATUS
01
SITE_LOCATION
130 S WILSON WAY
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
Scanner
SJGOV\kblackwell
Tags
EHD - Public
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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month ® 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181227 5/9/2023 <br /> Facility Name <br /> MCM14 AmPm <br /> Facility Address City ZIP Code <br /> 130 South Wilson Way Stockton 95205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Duncan Compliance: Dba R&D Compliance Testing 707 621-0378 <br /> Mailing Address <br /> P.O. Box 1503 Ukiah Ca. 95482 <br /> Service Technician Performing Test <br /> Ben'amin Duncan <br /> Contractor/Tank Tester License Number <br /> Contractor License #1036490 <br /> ICC Number ICC Expiration Date <br /> 5246802-UT 2/4/25 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Caldwell Systems Level Change Indicator 3/1/26 <br /> PEI/RP 1200 Certificate of Completion 5/4/24 <br /> Fiberglass Systems/NOV/CSI 4/22/24 <br /> XERXES Corporation 4/27/24 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Vacuum Tank Secondary Containment <br /> Pressure Product, Vent, Vapor Piping Secondary Containment <br /> Hydrostatic Piping Sumps/UDC's/Vent Box/Fill Riser Sumps <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. I understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 5/9/2023 5 <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 />
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