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Appendix V11 <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION Li Installation L Repair CJ 6 Murith 2 36 Month <br /> 1. FACILITY INFORMATtON <br /> OERS ID Test Date <br /> 10182131 0812012025 <br /> Facility Name <br /> Pilot 618 Ripon <br /> Facility Address fty fP Code <br /> ISO N. Jack Tone Rand Ripon 9536 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Janes Covey Croup Inc. (888) 72-7581 <br /> Maiting Address <br /> 9595 Lucas Ranch Road #100, Rancho Cucamonga, CA 91730 <br /> Service Technician Performing Test <br /> Shawn Rodriguez <br /> ContractodTank Tester License Number <br /> Contractor#8044311 Tank Tester#174766 <br /> ICO Number IOC Expiration Date <br /> 8412602 1,1012412026 1 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manofacturer and pest Equipmont Training Certifications Expiration Date <br /> Franklin Fueling Systems LVI-4 - #1021753712 10123/2026 <br /> Fiber Class Systems 051212026 <br /> 4, TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PE1120011 he Pressure Test 05PSI Al S Gcon d ary Lines <br /> InconlHydrostatic Test Aube Side&Truck Side UIX's and STP Sumps. <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby c ertify 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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 0812012025 27 <br /> ERS = Califomia Environmental Reporting System, IC = International Code Council. <br /> la = I de n tifir-a tion, NA = No Applicable, U DC = Under-Dispenser Con(ainmen1, <br /> Page 1 of 5 <br />