Laserfiche WebLink
Appendix VIl <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month Z 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />101814539 <br />Test Date <br />6117/2024 <br />Facility Name <br />Chevron 210997 <br />Facility Address <br />1442 W Colony Rd <br />City <br />Ripon <br />ZIP Code <br />95366 <br />.2. SERVICE TECHNICIAN ;INFORMATION <br />Company Performing the Test <br />Wayne Perry, Inc. <br />Phone <br />714-826-0352 <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 />300346 A B C611D40 HAZ <br />ICC Number <br />5116738 <br />ICC Expiration Date <br />1112112024 <br />3. TRAINING AND'CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Incon Level 4 <br />7/13/25 <br />Bravo SWAT #2019-2929491 <br />9/22/2026 <br />Xerxes #11911 <br />12/27/2024 <br />NOV <br />4/16/2027 <br />4. TEST PROCEDURE INFORMATION . <br />Test Procedures Used <br />Components Tested <br />PEI RP1200 <br />Annulars <br />PEI RP1200 <br />Secondary Lines <br />PEI RP1200 <br />UDC's <br />PEI RP1200 <br />Sumps <br />6. 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 96, 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 <br />�V_M <br />i <br />Date <br />6/17/2024 <br />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 />