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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION L3 Installation ❑ Repair ❑ 6 Month ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 9l2022 <br /> 10182111 1 Oil <br /> Facility Name <br /> Shell Food Mart <br /> Facility Address — City ZIP Code <br /> 2320 North El Dorado Street Stockton 95204 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test I Phone <br /> Elite IV Contractors 209-461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr Stockton, Ca 95205 <br /> Service Technician Performing Test <br /> Michal Kennard <br /> Contractor/Tank Tester License Number <br /> 1001331 <br /> ICC Number ICC Expiration Date <br /> _ _5254811 _ _ _ 17/6/2023__.____ <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certification_s Expiration Date <br /> Fiberglass Systems/ NOV Piping Systems 3/16/2024 <br /> F4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested I <br /> Pressure Testing Diesel product secondary piping_ <br /> Piping Soap Test Diesel product secondary piping <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 96, 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 ice:^ Date{ I Total # of Pages <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 />