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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION Q Installation ® Repair ® 6 Month © 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10748068 - San Joaquin EMD 1/17/2024 <br /> Facility Name <br /> Sunwest Chevron <br /> Facility Address City ZIP Code <br /> 2758 W Kettleman Lane Lodi <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> BZ Service Station Maintenance, Inc 916-371-2380 <br /> Mailing Address <br /> 1041 Triangle Ct, W Sacramento, CA 95805 <br /> Service Technician Performing Test <br /> Rhome Desbiens <br /> Contractor/Tank Tester License Number <br /> 433159 <br /> ICC Number ICC Expiration Date <br /> 8245558 11/21/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling INCON: 242928355 1/30/2025 <br /> BRAVO: 20202929871 12/1/2026 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI-RP1200-Vac-10Hg/1 hr Annular: <br /> PEI-RP1200-Press-5psi/1 hr Piping: <br /> INCON-TS1 000-Hyd-1 5min Sumps/UDCs: 1 STP <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 16, 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 Signature Date Total # of Pages <br /> 1/17/2024 <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 />