Laserfiche WebLink
Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month ® 36 Month <br /> 11.LFACC�ILITYINFORMATION <br /> C_ER S ID <br /> w Test Date <br /> �w wwww <br /> i 8W2022 <br /> Facility Name <br /> LVDP-Ripon CFN <br /> Facility Address <br /> 816 South Frontage Road City ZIP CodeRipon 195366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> , <br /> l wav vviN, wna.a esfiny 7A7 Cr1.1 A474 <br /> Mailing Address '"' -"""' <br /> �•U. Qvw lvvv vniu�i vv. ACA 49 <br /> V VTVt. <br /> Service Technician Performing Test <br /> Ben'amin F Duncan <br /> Contractor/Tank Tester License Number <br /> Tank Tester License#90-1120 <br /> ICC Number <br /> 5246802-U 1 <br /> ICC Expiration Date <br /> 3. TRAINING AND CERTIFICATIONS ��� II L;3 <br /> Manufacturer and Test Equipment Training Certifications <br /> Caldwell Systems/Level Change Indicator Expiration Date <br /> PEIIRP 1200 Certificate of Completion 6110/23 <br /> Fiberglass Systems/NOV/CSI-1-FS Pro Compliance Testing 514/24 <br /> �Modern Welding Company/Western Fiberglass, Inc, g 4122!24-4129123 <br /> TEST PROCEDURE INFORMATION 513124-4/21!23 <br /> Test Procedures Used Components Tested <br /> Vacuum Tank Secondary Containment <br /> Pressure ProductiVent/Vapor Piping Secondary Containment <br /> Hydrostatic Piping Sumps/UDC's/Fill Sumps <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> ►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 su ortin <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 ty <br /> a Date Total#of Pages <br /> 8!9/2022 5 <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 />