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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION 0 Installation I--1 Repair I_1 o ldor.th ® 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10165823 11/17/2020 <br /> Facillt�r Name <br /> 7-ELEVE #17647,MKT 2368(N-744) <br /> FaciIiy�Address City ZIP Code <br /> 1048 W.Y SEMITE AVE @ EL PORTEL MAN ECA 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Cor �a n Performing the Test Phone <br /> Tankno gy, n 800-964-1250 <br /> Mailing Address <br /> 11000 N pac Expy#500 Austin,TX 78759 <br /> Service Technician Performing Test <br /> Jarrod Cooke <br /> Contractor/Tank Tester License Number <br /> 743160 <br /> ICC Number ICC Expiration Date <br /> 5311523-UT 04/03/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> lake test stp/udc <br /> vac test annulars <br /> pressure test secondary lines <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the secondary containment was rested 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. f understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total#of Pages <br /> 11/17/2020 3 <br /> CERS = California Environmental Reporting System, ICC= International Code Council, <br /> ID = Identification, NA= Not Applicable, UDG= Under-Dispenser Containment, <br /> Page 1 of 5 <br />