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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form s <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month ® 36 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Test date <br /> 10181381 8/9/2022 <br /> Facility Name ww�� <br /> Angle Petroleum <br /> Facility Address �� City ZIP Code <br /> 341 East Main Street Ripon 95366 <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 - FFS Pro Compliance Testing 4/22/24 -4/29/23 <br /> XERXES 4/27/24 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Pressure Product Piping Secondary Containment <br /> Hydrostatic Piping 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 /> 8/9/2022 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 /> 1. ' <br />