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 /> 10422475 06/16/2021 <br /> Facility Name <br /> Yosemite Avenue ARCO Am Pm <br /> Facility Address City ZIP Code <br /> 1711 E. Yosemite Ave Manteca 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Diamond Petroleum Services, Inc. (925) 470-0803 <br /> Mailing Address <br /> 3619 King Ct Antioch CA 94509 <br /> Service Technician Performing Test <br /> Guadalupe Sanchez <br /> Contractor/Tank Tester License Number <br /> 1005444 <br /> ICC Number ICC Expiration Date <br /> 5250451 04/01/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW EVR UST VR-102# 0163755 06/05/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI12001Hydrostat Test 87M, 87S and 91 Fill Spill Buckets <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 /> 06/16/2021 2 <br /> CERS = California Environ menta Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />