Laserfiche WebLink
Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 3/31/2021 <br /> Facility Name <br /> Chevron <br /> Facility Address City ZIP Code <br /> 2615 Grantline Rd. Tracy 95304 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Pinnacle Fuel Compliance 408-206-9840 <br /> Mailing Address <br /> P.O. Box 32849 <br /> Service Technician Performing Test <br /> Jeff Conger <br /> Contractor/Tank Tester License Number <br /> 90-1116 <br /> ICC Number ICC Expiration Date <br /> 1081782 12/05/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS EVR Phase I —VR101 (Phil-tite) #1020003708 4/10/2021 <br /> OPW#104789 4/11/20211 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI 1200 Spill bucket integrity <br /> FFS EVR Phase I Spill bucket integrity <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that each spill container was tested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637.1; 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 /> 3/31/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />