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FEB/24/2021/WED 06: 05 PM Tracy Truck Stop FAX No, 209832 2312 P, 004
<br /> Appendix VII
<br /> Underground Storage Tank
<br /> Secondary Containment Testing Report Form
<br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 6 Month ❑ 36 Month
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<br /> a?i I N �' I CERS ID > I,l.;sl"tiia,.
<br /> Test Date
<br /> 10181251 2/10/2021
<br /> Facility Name
<br /> CD&R Tracy Boulevard Chevron
<br /> Facility Address City ZIP Code
<br /> 3775 North Tracy Boulevard Tracy 95304
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<br /> Company Performing the Test Phone
<br /> R&D Compliance Testi 707 621-037
<br /> Mailing Address
<br /> P.O. Box 1503 Ukiah Ca. 95482
<br /> Service Technician Performing Test
<br /> Benjamin Duncan
<br /> Contractor/Tank Tester License Number
<br /> Tank Tester License #90-1120
<br /> ICC Number ICC Expiration Date
<br /> 5246802-UT
<br /> 3/20/2021
<br /> 3t1119"RManofacturer and h
<br /> h
<br /> Caldwell SystemsCExpiration Date
<br /> 6/10/2023
<br /> ICC Service Technician #5246802-UT 3/20/2021
<br /> Underground Storage Tank Tester License #90-1120 12/31/2022
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<br /> Tesf Procedures Used Components Tested
<br /> Pressure Pipe Secondary Containment
<br /> - .Ifs? ', ,�.•:r' � 't � in = ��I� ' 1� I ' E4 Qf 1 �, 4 �r
<br /> I hereby certify that the secondary containment was tested in accordance with California
<br /> Code of Regulations, title 23, division 3, chapter 76, section 2637; that required supporting
<br /> documentat/on 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 /> �rusc�.a.�L 2/10/2021 5
<br /> CERS = California Environmental Reporting System, ICC = International Code Council,
<br /> ID ; Identification, NA ; Not Applicable, UDC = Under-Dispenser Containment,
<br /> Received Time Feb. 24, 2021 6 : 02PM No, 6614 Page 1 of
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