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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <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 />TYPE OF ACTION Installation Repair 6 Month 36 Month <br />CERS ID Test Date <br />Facility Name <br />Facility Address City ZIP Code <br />Company Performing the Test Phone <br />Mailing Address <br />Service Technician Performing Test <br />Contractor/Tank Tester License Number <br />ICC Number ICC Expiration Date <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />Test Procedures Used Components Tested <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 Date Total # of Pages <br />1. FACILITY INFORMATION <br />2. SERVICE TECHNICIAN INFORMATION <br />3. TRAINING AND CERTIFICATIONS <br />4. TEST PROCEDURE INFORMATION <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />10182131 12/10/2021 <br />Pilot Flying J 618 Ripon <br />1501 N. Jack Tone Rd. <br />Ripon 95366 <br />Jones Covey Group, Inc.(888) 972-7581 <br />8412602 11/13/2022 <br />Incon Level 4- Sump Tester 11/18/2022 <br />PEI-1200-Hydrostatic Test Tank 4: 87 STP Sump <br />12/10/2021 19 <br />9595 Lucas Ranch Road #100, Rancho Cucamonga, CA 91730 <br />Shawn Rodriguez <br />Contractor #804431 / Tank Tester #17-1766