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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month ® 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10181339 <br />Test Date <br />7/22/2021 <br />Facility Name <br />Super Stop Market <br />Facility Address <br />290 North Main Street <br />City <br />Manteca <br />ZIP Code <br />95336 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />R&D Compliance Testing <br />Phone <br />707 621-0378 <br />Mailing Address <br />P.O. Box 1503 Ukiah Ca. 95482 <br />Service Technician Performing Test <br />Ben'amin F Duncan <br />Contractor/Tank Tester License Number <br />Tank Tester License #90-1120 <br />ICC Number <br />5246802 -UT <br />ICC Expiration Date <br />2/17/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Caldwell Systems/Level Change Indicator <br />6/10/2023 <br />PEI/RP 1200 Certificate of Completion <br />5/4/2024 <br />Fiberglass Systems/NOV/CSI <br />4/22/2024 <br />Western Fiberglass, Inc. <br />4/21/2023 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />Vacuum <br />Tank Secondary Containment <br />Pressure <br />Product Piping Secondary Containment <br />Hydrostatic <br />Piping Sumps/UDC's <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I 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 <br />D� <br />Date <br />7/22/2021 <br />Total # of Pages <br />5 <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 />