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Appendix VII <br /> Underground Storage Tank <br /> _ Secondary Containment Testing Report Form <br /> TYPE OF ACTION ( Installation 97 Repair 6 Month ( 36 Month <br /> 11. .FActuTy INFORMATION <br /> CERS ID Test Date <br /> f <br /> 19-29-2021 <br /> Facility Name ---- <br /> Gas and Shop Truc <br /> Facility Address 1 City ZIP Code <br /> 1002 E. Fr ad Ripon CA 95366 <br /> TE I tCi1 f II IATfON <br /> Company Performing the Test Phone <br /> Self Serve Petroleum 650 588-3088 <br /> 1 Mailing Address <br /> F <br /> 1045 Airport Blvd. South San Francisco CA 94080I <br /> Service Technician Performing Test <br /> Robert Neimeyer <br /> ContractorlTank Tester License Number <br /> Gen A f Haz 930666 <br /> ICC Number : IGC Expiration Date <br /> 5240867 10-11-2021 l <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Caldwell systems 3-10-2024 <br /> S Bravo 3-26-2023 <br /> �NOV _ 5-25-2024 <br /> I I <br /> ARE I~IWMN <br /> Test Procedures Used Components Tested <br /> PEI .5jp_aU=a. tank annular, Product line secnQdary piping, <br /> tt:. SI=Ftk`ONICII#NQ. ucTING TEST <br /> A_. <br /> I hereby certW 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 Totai #of Pages <br /> 169411_� X/4 <br /> 9-29-2021 <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 />