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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION ❑ Installation ® Repair ❑ 6 Month <br />❑ 36 Month <br />1. FACILITY INFORMATION <br />CERS ID Test Date <br />10182103 05/16/2023 <br />Facility Name <br />United Pacific #5446 <br />Facility Address City ZIP Code <br />1403 Country Club Blvd. Stockton 95204 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />CGRS Inc. <br />Phone <br />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 <br />8711887 <br />ICC Expiration Date <br />08/28/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />F.F.S. Incon Level 4 TS -STS Sump Testing Cert. #1004793709 <br />05/04/2025 <br />S. Bravo Systems Cert. #2020-2929929 <br />12/04/2023 <br />NOV Fiberglass Systems <br />11/29/2024 <br />Triangle Manufacturing 5000w Level System Cert#TMI-167 <br />10/10/2024 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />RP -1200 / Cal CUPA Form <br />Tank Top Sumps 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: <br />Leo Rangel <br />Date <br />05/16/2023 <br />Total # of Pages <br />8 <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 />