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Appendix 1/11 21200138 <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION Installation Repair [:]6 Month 036 Month <br /> If:FACILITY INFORMATION r <br /> CERS ID Test Date <br /> 10180733 1/8/2021 <br /> Facility Name <br /> Arco 7147 <br /> Facility Address City ZIP Code <br /> 1206 E. March Lane Stockton 95210 <br /> 2. SERVICE TECHNICIAN INFORMATION s <br /> Company Performing the Test Phone <br /> Gettler-Ryan Inc. <br /> 925-551-7444 <br /> Mailing Address <br /> 6805 Sierra Court, Suite G, Dublin, CA 94568 <br /> Service Technician Performing Test <br /> Terrell Taylor <br /> Contractor/Tank Tester License Number <br /> 220793 <br /> ICC Number ICC Expiration Date <br /> 9315756 812312021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Incon Level 4 Tech Cert 11017713712 12/21/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic Sump Test UDC 7/8 and UDC 9/10 <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 7637; 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 /> f 1/8/2021 <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 />