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Appendix VII <br /> Underground Storage Tank 21200138.1 <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION Installation 7Repair [:]6 Month [:]36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 14180733 <br /> 1/11/2021 <br /> Facility Name <br /> Arco 7147 <br /> Facility Address City ZIP Code <br /> 1246 E. March Lane Stockton 95210 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Gettler-Ryan Inc. 925-551-7444 <br /> Mailing Address <br /> 6805 Sierra Court, Suite G, Dublin, CA 99568 <br /> Service Technician Performing Test <br /> Matthew Campbell <br /> Contractorfrank Tester License Number <br /> 220793 <br /> ICC Number ICC Expiration Date <br /> 8716847 2118/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Incon Lvel 4 Tech Cert 111008083711 12/9/2022 <br /> LC TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> IACon UDC <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signaturef Date Total # of Pages <br /> /,�Z 1/11/2021 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 />