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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month 17136 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10181447 <br />Facility Name <br />Mobil 4681 <br />Facility Address <br />2500 W. Lodi <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Able Maintenance, Inc. <br />Mailing Address <br />3224 Regional Parkway, Santa Rosa, CA 95403 <br />Service Technician Performing Test <br />Michael McCarter <br />Test Date <br />11/16/2022 <br />City ZIP Code <br />Lodi 95242 <br />Phone <br />(707) 545-5522 <br />Contractor/Tank Tester License Number <br />Able Maintenance, Inc. 1312844 <br />ICC Number ICC Expiration Date <br />,8819839 09124/2023 ; <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />INCON TS -STS L4.1019623710 09!2012024 <br />Modern Welding Tank Installer 00112024 <br />WF6 Co -Flax piping & Sumps 06116/2024 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Hydrostatic <br />Pressure <br />Vacuum <br />Components Tested <br />Sumps, UDC's <br />Secondary piping <br />Tank annuisrs <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />1 hereby certify that the secondary containment was tested In accordance with Callfomis <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 />`�' 11/'I QJ2022 5 <br />CERS = California Environmental Reporting System, ICL = International Code Council, <br />ID = Identification, NA = Not Applicable, UDC = Under -Dispenser Containment, <br />Page 1 of 5 <br />