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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 Test Date <br /> 10166883 10/21/2021 <br /> Facility Name <br /> Super Stores Industries <br /> Facility Address City ZIP Code <br /> 16888 McKinley Avenue Lathrop 95330 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> R&D Compliance Testing 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 ICC Expiration Date <br /> 5246802-UT 2/17/23 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Caldwell Systems/Level Change Indicator 6/10/23 <br /> PEI/RP 1200 Certificate of Completion 5/4/24 <br /> Fiberglass Systems/NOV/CSI 4/22/24 <br /> Western Fiberglass, Inc. 4/21/24 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Pressure Product Piping Secondary Containment <br /> Hydrostatic Piping Sumps/Fill Riser 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 Date Total # of Pages <br /> 10/21/2021 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 />