Laserfiche WebLink
Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair <br />® 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10184725 <br />Test Date <br />3/28/2023 <br />Facility Name <br />Chevron <br />Facility Address <br />2615 Grantline Rd. <br />City <br />Tracy <br />ZIP Code <br />95304 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Pinnacle Fuel Compliance <br />Phone <br />408-206-9840 <br />Mailing Address <br />P.O. Box 32849 <br />Service Technician Performing Test <br />Jeff Conger <br />Contractor/Tank Tester License Number <br />90=1116 <br />ICC Number <br />1081782 <br />ICC Expiration Date <br />11/10/2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />FFS EVR Phase I — VR101 (Phil=tite) #1020003708 <br />3/5/2025 <br />OPW #104789 <br />3/8/2025 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PEI 1200 <br />Spill bucket integrity <br />FFS EVR Phase I <br />Spill bucket integrity <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 <br />Date <br />3/28/2023 <br />Total # of Pages <br />2 <br />CERS =California Environmental Reporting System, ID =Identification, ICC =International Code <br />Council <br />Page 1 of 2 <br />