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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 /> 10181019 04/14/2022 <br /> Facility Name <br /> Tracy Market <br /> Facility Address City ZIP Code <br /> 15 E. Grant Line Road Tracy, CA 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> ECO-CHEK Compliance, Inc. 888-500-2435 <br /> Mailing Address <br /> PO Box 1394 Lafayette CA 94549 <br /> Service Technician Performing Test <br /> Marco Ale'os <br /> Contractor/Tank Tester License Number <br /> 958763 A <br /> ICC Number ICC Expiration Date <br /> 8415074 04/03/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Caldwell Level Change Indicator 05/31/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI-RP1200 Secondary Piping Runs and Tanks Annular Space <br /> Caldwell Systems/Hydrostatic 30 Minutes Secondary 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 qvailable upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 04/14/2022 5 <br /> kw, i I <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 />