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Underground Storage Tank, <br /> Primary Test Report Form <br /> TYPE OF ACTION 12 Installation 0 Repair 0 6 Month 0 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10182111 10/1712022 <br /> Facility Name <br /> Shell Food Mart <br /> T <br /> Facility Address City ZIP Code­ <br /> 2320 N. El Dorado St Stockton 195204 <br /> SERVICE TECHNICIAN INFORMATION <br /> ........... <br /> Company Performing the Test Phone <br /> Elite IV Conti-actors (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 7/6/2023 <br /> 3.TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Fiberglass Systems/ NOV Piping Systems 3/16/2024 <br /> [4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Pressure Testing Diesel Product Primary Piping <br /> Piping soap Test Diesel Product Primary Piping <br /> S. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> /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. / understand <br /> that test procedures shall be made available upon request by the governing authority, <br /> Service Technician Signature Date — — al #of Pages <br /> 1 OJ1 7/2022 .3 <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 />