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Appendix Vli <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION U Instar ail--rn a Repair El 6 Month Z 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 1016581tL5,y' 09/02/2021 <br /> Faci <br /> 7-ELLEVIEN#173334ryMKT 2368(N-747) <br /> Facility Address CiiZIP Code <br /> 4501 N.P RSHING AVE.@ ROSEMARIE LN. STO�y KTON 95207 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> 'a Performing the Test Phone <br /> Tanknol gy,InX. 800-964-1250 <br /> Mailin�q Address <br /> 11000 N opac Expy#500 Austin,TX 78759 <br /> Service Technician Performing Test <br /> Jarrod Cooke <br /> Contractor/Tank Tester License Number <br /> 743160 <br /> ICC Number ICC Expiration Date <br /> 8155550 03/18/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC:CA UST Service Technician 03/18/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> lake test sumps <br /> pressure test secondary lines <br /> vacuum test annulars <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the secondary containment was rested 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. f understand <br /> that test procedures chaff be made available upon request by the governing authority. <br /> Senrvice Technician Signature Date Total#of Pages <br /> /��� 09/02/2021 3 <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 />