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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑Installation ❑Repair ❑6 Month X 36 Month <br /> 1. FACILITY INFORMATION <br /> CER S ID Test Date <br /> 10184725 5/6/2021 <br /> Facility Name <br /> Chevron <br /> Facility Address City ZIP Code <br /> 2615 Grantline Road 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 /> Aneil Chand <br /> Contractor/Tank Tester License Number <br /> SWRCB 90-1262 <br /> ICC Number ICC Expiration Date <br /> 8455316 5/27/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Incon Sump Test System Cert#1001943708 5/26/2022 <br /> Caldwell Level Change indicator 2/28/2024 <br /> SWRCB Tank Testing License #90-1262 3/31/2023 <br /> ICC Technician, Installer, Operator Cert#8455316 5/27/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic /time Piping sumps, under dispenser sumps <br /> Vacuum /time Tank dry annulars / secondary containment <br /> Pressure /time product, vapor, vent secondary piping <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the secondary containment was tested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637; that required supporting documentation is <br /> attached;and all information contained herein is accurate. I understand that test procedures shall be <br /> made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 5/6/2021 9 <br /> 6. TANK SECONDARY CONTAINMENT TEST <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 />