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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <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 />TYPE OF ACTION Installation Repair 6 Month 36 Month <br />CERS ID <br /> <br />Test Date <br /> <br />Facility Name <br /> <br />Facility Address <br /> <br />City <br /> <br />ZIP Code <br /> <br />Company Performing the Test <br /> <br />Phone <br /> <br />Mailing Address <br /> <br />Service Technician Performing Test <br /> <br />Contractor/Tank Tester License Number <br /> <br />ICC Number <br /> <br />ICC Expiration Date <br /> <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br /> <br />Test Procedures Used Components Tested <br /> <br /> <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 <br /> <br />Total # of Pages <br />1. FACILITY INFORMATION <br />2. SERVICE TECHNICIAN INFORMATION <br />3. TRAINING AND CERTIFICATIONS <br />4. TEST PROCEDURE INFORMATION <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />10132636 04/22/2024 <br />Flyers #487 <br />983 Moffat Blvd.Manteca 95336 <br />Nwestco LLC (800) 339-9930 <br />2209 Zeus Court, Bakersfield, CA 93308 <br />Billy Lane <br />1073967 <br />10281488 03/15/2025 <br />INCON 1022163714 11/08/2024 <br />Incon Sumps and UDC’s <br />Precision mechanical test gauge Tank annular’s and line secondaries <br />04/22/2024 5