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SR0083263 Amended <br /> Appendix VII <br /> Primary Underground Storage Tank <br /> SieeesWemy Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation Z Repair ❑ 6 Month rl 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 1 o I g P o65 5/18/2021 <br /> Facility Name <br /> Country Mart Gas & Food <br /> Facility Address City ZIP Code <br /> 34243 Chrisman Road Tracy 95304 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Elite IV Contractors 209 461-6337 <br /> Mailing Address <br /> 2535 Wigwam Drive Stockton CA 95205 <br /> Service Technician Performing Test <br /> Joe Bartholdi <br /> Contractor/Tank Tester License Number <br /> 1001331 1 A-Hazmat <br /> ICC Number ICC Expiration Date <br /> 8852851 4/13/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC UST Service Technician 4/13/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Pressure Test Primary Line at 45 PSI <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> l 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 T nici Si ture Date Total ## of Pages <br /> 5/1812021 2 <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 />