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WWI M=h-afflm <br /> Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> Z� TYPE OF ACTION ❑ Installation <br /> El Repair ❑ 6 Months El 36 Month <br /> CACILITY INFORMATION Test Date <br /> 031211202.3 <br /> GEES ID <br /> 10134451 <br /> Facility Name <br /> 1�6ZIP Code <br /> Unocal 76 City <br /> Facility Address Stockton 95219 <br /> L!701'Nest March Lane <br /> 2. SERVICE TECHNICIAN INFORMATION Phone <br /> Company Performing the Test (707)545-5522 <br /> Able Maintenance,Inc. <br /> Mailing Address <br /> 3224 RiagionaI Parkway,Santa Rosa CA 95403 <br /> Service Technician Performing Test <br /> Eusebio Sousa <br /> Contractor/Tank Tester License Number <br /> Able Maintenance,Inc./312844 ICC Expiration Date <br /> ICC Number 0612512023 <br /> 5254516 <br /> 3. TRAINING AND CERTIFICATIONS Expiration Date <br /> Manufacturer and Test Equipment Training Certifications <br /> 0312012024 <br /> INCON TS-STS L4-1012573708 <br /> rN <br /> 4. TEST PROCEDURE INFORMATION <br /> i <br /> Test Procedures Used Components Tested <br /> Hydrostatic UDC's <br /> Pressure Secondary piping <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the secondary containment was tested in accordance with California <br /> L <br /> Regulations, title 23, division 3, chapter 16, section 2637; that required supporting <br /> ntation is attached; and all information contained herein is accurate. I understand <br /> procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature // Date Total # of Pages <br /> 0312112023 4 <br /> CERS = California Environmeal Reporting System, ICC = International Code Council, <br /> ID = Identification, NA = Not Applicable, UDC = Under-Dispense containment, <br /> Page 1 0' <br />