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Appendix VII Received via CERS <br /> CERS submittal 8/15/2025 <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION [ Installation 17 Repair r7 6 Month © 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181059 06/27/2025 <br /> Facility Name <br /> Quik Stop Market #137 <br /> Facility Address City ZIP Code <br /> 1153 Lincoln Blvd Tracy 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Walton Engineering 916 373 1166 <br /> Mailing Address <br /> 3900 Commerce Drive, West Sacramento <br /> Service Technician Performing Test <br /> Tyler Balderston <br /> Contractor/Tank Tester License Number <br /> 617238 <br /> ICC Number ICC Expiration Date <br /> 8472064 06-21-2027 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OMNTEC Proteus CLD Series 06-23-2027 <br /> Bravo 2018-2929131 05-27-2027 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Vacuum Decay Tank annular <br /> Pressure Decay Secondary Product Line <br /> Proteus CLD Containment Sumps <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 Signature Date Total # of Pages <br /> 06/27/2025 8 <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 />