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Appendix V11 <br /> Underground Storage Tank <br /> Secondary Containment Testing Deport Form <br /> TYPE OF ACTION LM Installation Repair 6 Month 16 Month <br /> 1. FACILITY INFORMATION _ <br /> ERS lD Test Date <br /> 10180551 - San ,boa uln EMD 314125 <br /> Facility Name <br /> CHEVRON <br /> Facility Address City ZIP Code <br /> 444 MOSSDALE RD LATHR P 95330 <br /> . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test phone <br /> BZ Service Station Maintenance, Inc 916-371-2380 <br /> Mailing Address <br /> 1041 Triangle Dt, W Sacramento, CA 98805 <br /> Service Technician Performing Test <br /> Jeff Raven <br /> DcntractodlTank Tester License Number <br /> 433159 <br /> ICC Number ICC Expiration Date <br /> 9326216 710112025 <br /> . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling 1N ON: 1016313710 311012025 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI-RP180-11ac-10Hg11hr Annulars: l <br /> PEI-RPI200-Press-5psillhr Piping. 3 Sec lines <br /> If CON-TS1000-Hyd-15min SumpslUD s: 9 <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the secondary containment was tes#ed in accordance with Califomia <br /> Dods of Regulations, tette 23, division 3, chapter 16, sec#tart 2637, that required supporting <br /> documentation is attached, and all information contained herein is accura#e. ! understand <br /> that tis#pro edur�es shaf acle v Mable e� -on request by the goveming authority. <br /> service Technician Signet Date Total # of Pages <br /> ` 314125 T <br /> CERS = California Environmental Reporting System, ICC = International Code Council, <br /> IIS = Identification, NA = Not Applicable, UDC = Under-Dispenser Containment, <br /> Page 1 of 5 <br />