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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION C Installation ❑Ir Repair 6 Month 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181267 10/12/2023 <br /> Facility Name <br /> Stockton AASF <br /> Facility Address City ZIP Code <br /> 2000 Stimson Rd Stockton 95206 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Baseline Enterprises DBA Central Coast Tank Testing (805) 687-6640 <br /> Mailing Address <br /> P.O. Box 2155, Santa Barbara, CA 93120 <br /> Service Technician Performing Test <br /> Jerry Brooks <br /> Contractor/Tank Tester License Number <br /> CSLB#873533 <br /> ICC Number ICC Expiration Date <br /> 8146908 08/31/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Incon Sump Test System #1016093709 11/24/24 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI/RP1200 Tank Secondary, Line Secondary, Sumps, UDCs <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 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 /> Servic echnician S' acture Date Total # of Pages <br /> 10/12/2023 6 <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 />