Laserfiche WebLink
Appendix Vill <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION El Installation 0 Repair 0 6 Month 0 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10182111 5/4/2023 <br /> Facility Name <br /> El Dorado Food Mart <br /> Facility Address City ZIP Code <br /> 2320 E-1 Dorado St Stockton 95204 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Elite IV Contractors (209)461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr Stockton, Ca 95205 <br /> Service Technician Performing Test <br /> Michal Kennard <br /> Contractor/Tank Tester License Number <br /> 1001331 <br /> ICC Number <br /> 'C Expiration Date <br /> 5254811 7 7/6 C12'3- <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Fiberglass Systems NOV Secondary Contaiment Piping Systems 3/16/2024 <br /> Fiberglass Systems NOV -CSI Tank - Fiberglass Tank & DW Sumps 412312024 <br /> Caldwell Systems/Level Change Indicator 4/2024 <br /> 14. TEST PROCEDURE INFORMATION <br /> - <br /> Test Procedures Used Components Tested <br /> Line Presure Test Diesel Secondary Containment Piping <br /> Hydrostatic Diesel &_91 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 /> 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 />