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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month 0 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10180643 08/08/2025 <br /> Facility Name <br /> Quik Stop Market 125 <br /> Facility Address City ZIP Code <br /> 1580 W Main St Ripon 95366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Service Station Systems (408)971-2445 <br /> Mailing Address <br /> 680 Quinn Ave San Jose CA 95112 <br /> Service Technician Performing Test <br /> Anthony Reyes <br /> Contractor/Tank Tester License Number <br /> 485184 <br /> ICC Number ICC Expiration Date <br /> 8293772 07/30/2026 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OEL8000111-CLD Proteus Series#AR4567379 01/16/2027 <br /> Bravo B2000#20182929313 05/10/2027 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Vacuum decay Tank Annulars <br /> Pressure Decay Product Piping secondary <br /> Hydrostatic 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 available upon request by the governing authority. <br /> Service Technician Si atu e Date Total # of Pages <br /> 08/08/2025 5 <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 />