Laserfiche WebLink
A UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page,1 of 6) <br /> Type of Action ❑Installation Test ❑Repair Test ❑Six Month Test E 36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 10181653 1 11/07/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Chevron 201761 <br /> Business Site Address City ZIP Code <br /> 1103 S Main Street Manteca 95337 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the/CC Certification.) Phone# <br /> Nick Harvey (916)834 - 5099 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 300345 A B C61/D40 HAZ 5115738 02/13/2019 <br /> III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> Tank ID:(By tank number,stored product,etc.) A 87 Main B 87 Aux C 91 D <br /> Tank Containment <br /> Tightness Test Result E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> 01 <br /> Product Piping Containment '; ; e .:. ... <br /> Tightness Test Result E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Remote Fill Piping Containment ' 4 <br /> p 9 x ' <br /> Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑ NA <br /> k s <br /> Vent Piping Containment . �' .. <br /> Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> 01 <br /> Vapor Recovery Piping Containment WS", gi <br /> ., <br /> Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑ NA <br /> Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> ' t Ago- <br /> Turbine/Product Piping SumpN, <br /> Tightness Test Result E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Fill Riser Sump <br /> Tightness Test Result E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Vent/Transition Sump ID: a b C d <br /> Tightness Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> UDC ID: 1 1/2 23/4 3 5/6 4 7/8 <br /> Tightness Test Result E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑ NA <br /> UDC ID: 59/10 611/12 7 8 <br /> Tightness Test Result E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> UDC ID: 9 110 Ill 112 <br /> Tightness Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA I❑Pass ❑Fail ❑ NA I ❑Pass ❑Fail ❑NA <br /> All items marked"Fail"or"N/A"must be explained in their respective"COMMENTS"section. <br /> IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the secondary containment was tested in accordance with California Code of Regulations,title 23, <br /> division 3,chapter 16,section 2637 and all the information contained herein is accurate. <br /> UST Service Technician Signature N A � <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=International Code Council, <br /> NA=Not applicable,UDC=Under-dispenser containment <br />