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Appendix Vll <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE of ACTION ❑ installation ❑ Repair ❑ 6 Month ® 36 Month <br /> 1::: I: CIII Y.IIVFOR G <br /> CERS ID Test Date <br /> 10194299 02/06/2023 <br /> Facility Name <br /> Chevron 209167 <br /> Facility Address City ZIP Code <br /> 1234 E Yosemite Ave Manteca 196336 <br /> IC-E T.EC CF, 6i1 INI ,OF IItIi�►'f10N.: <br /> :.. <br /> Company Performing the Test Phone <br /> Wayne Perry, Inc. 714-826-0352 <br /> Mailing Address <br /> 8281 Commonwealth Avenue, Buena Park CA 90621 <br /> Service Technician Performing Test <br /> Dick Harvey <br /> Contractor/Tank Tester License Number <br /> 300346 A B C61ID40 HAZ <br /> ICC Number ICC Expiration Date <br /> 5115738 1112'112024 <br /> ,3 :'I'RAIN[ G'-. PD:GER- IF .A� ION. <br /> Manufacturer and Test Equipment Training Certifications Expiration Bate <br /> Incon Level 4 7/28123 <br /> Bravo SWAT#2019-2929491 �_ 9/2512023 <br /> Xerxes 911911 12127/2024 <br /> NOV �- — 4/2612024 <br /> �I..qI T---PROCEDU.R15ImmFg1 V. <br /> k.Test Procedures Used Components Tested <br /> PEI RP1200 Annulars <br /> PEI RP1200 Secondary Lines <br /> PEI RP1200 UDC"s <br /> PEI RP1200 Sumps <br /> CERT:IFtGA'CI.QN.AY.S f.. ICE.:TECH.I I ,AN.CQI D,U TI IG'TEST. <br /> I hereby certify that the secondary containment was tested in accordance with California <br /> Code of Regulations,title 23, division 3, chapter 16, section 2637; that required supporting <br /> documentation is attached;and all information contained herein is accurate. l understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature ,[ Date Total#of Pages <br /> 02/06/2023 <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 />