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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION © Installation © Repair 6 Month ® 36 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10180641 10 - 15 -2020 <br /> Facility Name <br /> Quik Stop Market # 3148 <br /> Facility Address City ZIP Code <br /> 205 W . Lockeford Street Lodi 95240 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Walton Engineering 916 -372 - 1888 <br /> Mailing Address <br /> P . O . Box 1025 , West Sacramento , CA 95691 <br /> Service Technician Performing Test <br /> Anthony Reyes <br /> Contractor/Tank Tester License Number <br /> 617238 <br /> ICC Number ICC Expiration Date <br /> 8293772 9 -2 -2020 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling Systems level 4 # 1003213709 2 =22 =21 <br /> 4 . TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Vacuum Decay Tank Annular <br /> Pressure Decay Secondary Lines <br /> Incon STS Sumps and UDC 's <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 /> Anthony Reyes 10 = 15 -2020 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 />