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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION Q Installation © Repair ® 6 Month �I 36 Month <br />1. FACILITY INFORMATION <br />CERS 1%��� <br />` <br />Test Date10 <br />06-11-24 <br />Facility Name <br />LODICHEVRON <br />Facility Address <br />601 E KETTLEMEN DR <br />City <br />LODI <br />ZIP Code <br />95240 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />BZ Service Station Maintenance, Inc <br />Phone <br />916-371-2380 <br />Mailing Address <br />1041 Triangle Ct, W Sacramento, CA 95805 <br />Service Technician Performing Test <br />Jeff Raven <br />Contractor/Tank Tester License Number <br />433159 <br />ICC Number <br />9326216 <br />ICC Expiration Date <br />7/01/2025 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling INCON: 1016313710 <br />3/10/2025 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PEI-RP1200-Vac-10Hg/1 hr <br />Annular: 1 <br />PEI-RP1200-Press-5psi/1hr <br />Piping: 0 Sec lines <br />INCON-TS1 000-Hyd-1 5min <br />Sumps/UDCs:0 <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. I understand <br />that test procedures shat ade v Yab/e y -on request by the governing authority. <br />Service Technician Signat <br />Date !/I <br />Lt/il�� <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 <br />