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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION Ainstallation ā¯‘Repair [16 Month X36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181267 10-21-2020 <br /> Facility Name <br /> SI tockton AASF <br /> Facility Address TCity ZIP Code <br /> 2000 Stimson Rd Stockton 95206 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Tank Team inc - _ 805-432-0216 <br /> ---- -- - - - <br /> Mailing Address <br /> 2745 Sherwin Ave., Ste 8, Ventura, CA 93003 <br /> Service Technician Performing Test <br /> Bernard Olson <br /> Contractor/Tank Tester License Number <br /> 512835 <br /> ICC Number ICC Expiration Date <br /> 5252993 UT 8-21-2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications _ Expiration Date <br /> Incon STS 1000103709 Dec 21, 2021 <br /> I <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI 1200 Section 6.2 Double walled piping <br /> Double walled tank <br /> containment sumps <br /> S. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the secondary containment was tested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637; that required supporting documentation is <br /> attached; and all information contained herein is accurate. I understand that test procedures shall be <br /> made available up req t the governing authority. <br /> Service Tech r Date Total # of Pages <br /> 10-21-2020 4 <br /> 6. TANK SE60NDARY CONTAINMENT TEST <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 />