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Section V1 <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION [1�-- Installation Repair ❑ 6 Month ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 1/14/2021 <br /> Facility Name <br /> Waterloo Liquor <br /> Facility Address City County Zip Code <br /> 2512 Waterloo Rd Stockton �� U �r 95205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Elite IV Contractors (209) 641-6337 <br /> Mailing Address <br /> 2535 Wigwam Drive <br /> Contractor/Tank Tester License Number <br /> 101331-HAZ <br /> Service Technician Performing Test <br /> Gilbert Garcia <br /> ICC Number ICC Expiration Date <br /> 1864 3/26/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling INCON: FFS EVR Phase I Systems VR-101 3/26/2021 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI/RP12001Vacuum Test/10Hg for 1 hr Annular: <br /> PEI/RP1200/Pressure Test/5 psi for 1 hr Piping: <br /> INCONITS10001Hydrostatic- 15min Sumps/UDCs: <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> /hereby certify that the secondary containment was tested in accordance with California Code of <br /> Regulations, title23, d1v1sion3, chapter 16,section2367;thatrequiredsupportingdocumentationis <br /> attached;and all information contained herein is accurate. l understand that test procedures shall <br /> be made available upon request by the governing authority. <br /> Servic Technician Signature., Date Total # of Pages <br /> 1/14/2021 6 <br /> Page 1 of 6 <br />