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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION © Installation © Repair © 6 Month <br />© 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />Test Date <br />10180641 <br />10=15=2020 <br />=Facilityme <br />Market #148 <br />Facility Address <br />205 W. Lockeford Street <br />City <br />Lodi <br />ZIP Code <br />95240 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Walton Engineering <br />Phone <br />916-372-1888 <br />Mailing Address <br />P.O. Box 1025, West Sacramento, CA 95691 <br />Service Technician Performing Test <br />Anthony Reyes <br />Contractor/Tank Tester License Number <br />617238 <br />ICC Number <br />8293772 <br />ICC Expiration Date <br />9-2-2020 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling Systems level 4 #1003213709 <br />2'22'21 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />Vacuum Decay <br />Tank Annular <br />Pressure Decay <br />Secondary Lines <br />Incon STS <br />Sumps and UDC's <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST I III <br />1 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 <br />Total # of Pages <br />Anthonv Reves 10-15-2020 <br />5 <br />CERS =California Environmental Reporting System, ICC =International Code Council, <br />ID =Identification, NA =Not Applicable, UDC = Under -Dispenser Containment, Page 1 of 5 <br />