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Appendix W; <br /> Underground Storage Tann <br /> Secondary Containment Testing Report Fora <br /> TYPE OF ACTION 771 Installation Cl Repair C 6 Month j7 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 4-13-2020 <br /> Facility Name <br /> Gas and Shop <br /> Facility Address City ZIP Code <br /> 1002 E. Frontage Road Ripon CA 95366 <br /> ' 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Self Serve Petroleum 650 588-3088 <br /> Mailing Address <br /> 1045 Airport Blvd South San Franrisrn CA AanRn <br /> Service Technician Performing Test <br /> Robert Neimeyer <br /> Contractor/Tank Tester License Number <br /> Gen A/ Haz 930666 <br /> ICC Number ICC Expiration Date <br /> 5248067 10-9-2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Caldwell systems 3-10-2024 <br /> S Bravo 3-26-2023 <br /> NOV 5-25-2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI secondary piping, tank annular, tank ctrcumns,t rn("S <br /> 6. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> / 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. l understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Tec ni is Si tur Date Total # of Pages <br /> '4 4-13-2022 <br /> V <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 />