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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 /> 10181653 01/24/2025 <br /> Facility Name <br /> Chevron 201761 <br /> Facility Address City ZIP Code <br /> 1103 S Main Street Manteca 96337 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Wayne PerrV, Inc. 714-826-0352 <br /> Mailing Address <br /> 8281 Commonwealth Avenue Buena Park CA 90621 <br /> Service Technician Performing Test <br /> Gonzalo Gomez <br /> Contractor/Tank Tester License Number <br /> 300345 A B C61111340 HAZ <br /> ICC Number ICC Expiration Date <br /> 8231233 10/18/2026 <br /> 3 TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Incon Sump Test System - Level 4 11/26/2026 <br /> 1.4..:TEST.PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI RP1200 Annular <br /> PEI RP1200 Secondary <br /> PEI RP1200 Sumps <br /> PEI RP1200 UDC's <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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority, <br /> Service Technician Signature Date Total #of Pages <br /> 01/24/2026 <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 />