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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION R1 Installation R1 Repair ❑ 6 Month ❑ 36 Month <br />1. FACILITY INFORMATION <br />CERS ID Test Date <br />10181339 06/30/2022 <br />Facility Name <br />Super Stop Gas & Liquor <br />Facility Address City ZIP Code <br />290 N. Main St. Manteca 95336 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Tank -Tight Systems, Inc. <br />Phone <br />916-667-6891 <br />Mailing Address 8515 Waterman Rd. Elk Grove Ca. 95624 <br />Service Technician Performing Test <br />Brian Roth <br />Contractor/Tank Tester License Number <br />ICC Number 8834817 <br />ICC Expiration Date <br />11/14/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Installation & Replacement of Vaporless Manufacturing, Inc Mechanical Line Leak Detector <br />10/23/2023 <br />Veeder Tec ATG Installer #A29945 <br />10/24/2023 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />Vacuum <br />Annulars <br />Pressure <br />Secondary Lines <br />Hydrostatic <br />Turbin Sumps And UDCs <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 <br />Date <br />06/30/2022 <br />Total # of Pages <br />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 />