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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation 0 Repair ❑ 6 Month ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 12/14/2022 <br /> Facility Name <br /> Tiwana Gas and Food <br /> Facility Address City ZIP Code <br /> 1210 E Hammer Lane Stockton 95210 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Nwestco LLC (800)339-9930 <br /> Mailing Address <br /> 2209 Zeus Court, Bakersfield,CA 93308 <br /> Service Technician Performing Test <br /> Terrence Lay <br /> Contractor/Tank Tester License Number <br /> 1073967 <br /> ICC Number ICC Expiration Date <br /> 8721725 08/08/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> INCON 1012003709 02/07/2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Incon Sumps and UDC's <br /> Precision mechanical test gauge Product secondaries <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 /> / Digitally signed by Terrence Lay 12/14/2022 4 <br /> / Date: 2022.07.08 07:48:36-07'00' <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 />