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Appendix VII 22201552 <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION Installation Repair 06 Month 036 Month <br /> 1. FACILITY INFORMATION <br /> CERS 1D Test Date <br /> 101$2141 <br /> 6/3/2022 <br /> Facility Name <br /> Arco 2196 <br /> Facility Address City ZIP Code <br /> 3212 N. California Stockton 95204 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Gettlar-Ryan Inc. <br /> 925-551-7444 <br /> Mailing Address <br /> 6805 Sierra Court, Suite G, Dublin, CA 94568 <br /> Service Technician Performing TestRobertJacobs <br /> Contractor/Tank Tester License Number <br /> 220793 <br /> ICC Number ICC Expiration Date <br /> $819943 6/25/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root ATG Tech Cert #C23345 1/15/2023 <br /> Incon Level 4 Sump Testing Tech Cert 11102$323709 1/21/2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic All Sumps & UDC's <br /> Vacuum All Annular Tanks <br /> Pressure All Secondary Lines <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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 6/3/2022 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 />