Laserfiche WebLink
' Appendix Vff <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑installation ❑Repair 06 Month X 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 18184725 2121/2022 <br /> Facility Name <br /> Chevron <br /> Facility Address City Z!P 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 /> Aneii Chand <br /> ContractorlTank Tester License Number <br /> SWRCB 90-1262 <br /> ICC Number JCC Expiration Date <br /> 8455316 5/27/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> NOV - 2/18/2024 <br /> Caldwell Level Change Indicator 2/28/2424 <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 /> Fest Procedures Used Components Tested <br /> Hydrostatic 1 time Piping sumps, under dispenser sumps <br /> Vacuum f time Tank dry annuiars 1 secondary containment <br /> Pressure 1 time product, vapor, vent secondary piping <br /> 5. 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 16, section 2637,that required supporting documentation is <br /> attached;and all information contained herein is accurate. 1 understand that test procedures shall be <br /> made available upon request by the governing authority. <br /> Service Technician Signature Date Total #of rages 1 <br /> = - . �f' 2/2112022 6 <br /> 6_ TANK SECONDARY CONTAINMENT TEST <br /> CERS = California Environmental Reporting System, ]CC = International Code Council, <br /> ID = Identification, NA = Not Applicable, UDC � Under-Dispenser Containment, <br /> Page 1 of 5 <br />