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� CGRS Appendix VII <br /> SOLUTIONS DEL,,,EREF, Underground Storage Tank <br /> Secondary Containment Testing Report <br /> TYPE OF ACTION Form ❑ Installation ❑ Repair ❑ 6 Month th <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181885 01-08-2021 <br /> Facility Name <br /> Valley Pacific Petroleum <br /> Facility Address City ZIP Code <br /> 930 E Victor Rd. Lodi 95204 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> CGRS Inc. 916 991-1100 <br /> Mailing Address <br /> 5444 Dry Creek Road; Sacramento CA. 95838 <br /> Service Technician Performing Test <br /> Garrett Warren <br /> Contractor/Tank Tester License Number <br /> CSLB#803616 <br /> ICC Number ICC Expiration Date <br /> 8185019 09/20/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder-Root B42126 12-07-2022 <br /> Incon ST-STS Sump Tester Level 4 Cert. #1000553709 01/07/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> RP-1200 / Cal CUPA Form Tank Annulars, Product Line Secondaries, UDCs & Tank Top Sumps <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. 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 /> Garrett Warren ���� 01-08-2021 7 <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 />