Laserfiche WebLink
Appendix VII � 3 <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ® Installation ❑ Repair 6 Month ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181085 2/25/2022 <br /> Facility Name <br /> Chrisman Rd. 76 <br /> Facility Address City ZIP Code <br /> 34243 S. Chrisman Rd. Tracy 95304 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Elite IV Contractors (209)461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr. Stockton CA 95205 <br /> Service Technician Performing Test <br /> Adrian Rodriquez <br /> Contractor/Tank Tester License Number <br /> 1001331/ A-Hazmat <br /> ICC Number ICC Expiration Date <br /> 9914593 4127/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC UST Service Tech 4/27/2023 <br /> Fiber Glass System Nov 3/16/2025 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Industry Standard Secondary Line <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the secondary containment was tested in accordance with California <br /> Code of Regulations, title 23, division 3, chapter 96, section 2637, 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 Sidnature Date Total # of Pages <br /> 2/2512022 2 <br /> CERS = California Environmental Reporting System, ICC = International Code Council, <br /> ID = Identification, NA = Not Applicable, UDC = Under-Dispenser Containment, <br /> Page 1 of <br />