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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ® Repair ❑ 6 Month ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10180781 05/17/2023 <br /> Facility Name <br /> United Pacific #5447 <br /> Facility Address City ZIP Code <br /> 1460 East Hammer Lane Stockton 95201 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> CGRS Inc. 916 991-1100 <br /> Mailing Address <br /> 5444 Dry Creek Road• Sacramento CA. 95838 <br /> Service Technician Performing Test <br /> Leo Rangel <br /> Contractor/Tank Tester License Number <br /> CSLB#803616 <br /> ICC Number ICC Expiration Date <br /> 8711887 08/28/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> F.F.S. Incon Level 4 TS-STS Sump Testing Cert. #1004793709 05/04/2025 <br /> S. Bravo Systems Cert. #2020-2929929 12/04/2023 <br /> NOV Fiberglass Systems 11/29/2024 <br /> Triangle Manufacturing 5000w Level System Cert#TMI-167 10/10/2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> RP-1200 / Cal CUPA Form Product Line Secondaries 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: Date Total # of Pages <br /> Leo Rangel 05/17/2023 7 <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 />