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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION D Installation U Repair U n Month R1 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10166191 08/17/2023 <br /> Facility Name <br /> 7 ELEVEN 35355 <br /> Facility Address City ZIP Code <br /> 3202 W HAMMER LANE(N-136) STOCKTON 95209 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test <br /> Pho:�V <br /> Tanknology, Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N Mopac Expy#500 Austin,TX 78759 <br /> Service Technician Performing Test <br /> Jarrod Cooke <br /> Contractor/Tank Tester License Number <br /> 743160 <br /> ICC Number ICG Expiration Date <br /> 8155550 03/08/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC:CA UST Service Technician 03/08/2025 <br /> PE I:RP 1200 06/05/2079 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> lake test stp/udc sumps <br /> pressure test secondary lines <br /> vacuum test annular spaces <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the secondary containment was rested in accordance with California <br /> Code of Regulations, title 23, division 3, chapter 16, section 2637; that required supporting <br /> documentation is arrached; 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 Technician Signature Date Totai # of Pages <br /> 08/17/2023 5 <br /> CERS = California Environmental Reporting System, ICC = International Code Council, <br /> ID = ldentification. NA = Not Applicable, UDC = Under-Dispenser Containment, <br /> Page 1 of 5 <br />