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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month M 36 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181479 2022-09-20 <br /> Facility Name <br /> Mid City Ca FO Regen <br /> Facility Address City ZIP Code <br /> 13850 Devries Road Lodi 95242 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> SunWest Enqineering Constructors Inc 888 588-8737 <br /> Mailing Address <br /> 4780 Cheyenne Way, Chino CA 91710 <br /> Service Technician Performing Test <br /> Leonardo Aguilar, Jr. <br /> Contractor/Tank Tester License Number <br /> 703190 <br /> ICC Number ICC Expiration Date <br /> 5302718 12/2/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS Sump Test System Operation INCON Level 4 10/22/2023 <br /> Xerxes 4/1 /2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Industry standard All secondary containment components <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <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. 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 /> 2022-09-20 6 <br /> CERS = California Environmental Reporting System , ICC = International Code Council , <br /> ID = Identification , NA = Not Applicable , UDC = Under-Dispenser Containment, <br /> Page 1 of 6 <br />