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Appendix1l11 <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ElI n t ll tion F-IlRepair E16 Month X 36 Month <br /> ! FACILITY INFORMATION <br /> I — <br /> CERS ID — ... - . Test Date <br /> 101 84725. 516/2021 <br /> Facility Name <br /> Chevron <br /> Facility Address city l;' Code- <br /> 2615 G <br /> ode2 1 rantline Road Tracy 95304 <br /> . <br /> SERVICE TECHNICIAN-INFORMATION Company Performing the Test ' Phone <br /> Pinnar ie Fuel Compliance 408-206-9840 <br /> Mailing AddressP.O. Box 32849 <br /> j <br /> Service Technician Performing Test <br /> Aneil Chard <br /> ContractoriTank Tester License Number <br /> SWRDB 90-1262 <br /> ICC Number �-_- -- -- —_ -- � 'i ICC Expiration Date <br /> 845531 5/2712022 <br /> . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Incon Sump Test Syslem Cert#100194370 5125!2022 <br /> Caldwell Level Change indicator 2128!2024 <br /> i <br /> WR S Tank TestIng License #90-1262 13/31/2023 <br /> ICC Technician, Installer, Operator Cert# 8455310 5/2712022 <br /> 14. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested - — - - <br /> Hydrostatic I time Piping sumps, under dispenser sumps <br /> Vacuum / time Tank airy annulars I secondary containment— <br /> Pressure <br /> ontarinment - <br /> Pres ure 1 time product, vapor, gent secondary piping <br /> C . CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST .� <br /> 1 hereby certify that the secondary containment was tested in accordance with California code of <br /> Regulations, title 23, division 3, chapter 1 , section 2637; that required supporting documentation is <br /> attached; and aii information contained herein is accurate. 1 understand that test procedures shall he <br /> made available upon request by the governing authority. i <br /> Service Technician signature Date Total # of Pages <br /> 516/20211 9 <br /> 67. _TANK SECONDARYI T I MEI T TEST <br /> ERS = California Environmental Reporting System, ICC = Int rnati n ; Code Council, <br /> ID - Identification, NA - foot Applicable, UDC = Under-Dispenser Containment, <br /> Page I of <br />