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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month x36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10182265 <br />Test Date <br />10/16/2020 <br />Facility Name <br />ARCO AM PM # 82602 <br />Facility Address <br />2430 Joe Pombo Pkwy <br />City <br />Tracy <br />ZIP Code <br />95376 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Diamond Petroleum Services, Inc. <br />Phone <br />(925) 470-0803 <br />Mailing Address <br />3619 King Ct Antioch, CA 94509 <br />Service Technician Performing Test <br />Guadalupe Sanchez <br />Contractor/Tank Tester License Number <br />1005444 <br />ICC Number <br />5250451 <br />ICC Expiration Date <br />04/04/2021 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />NOV FIBER GLASS SYSTEMS <br />11/29/2020 <br />CALDWELL SYSTEMS <br />0612022 <br />ZCLIXERXES <br />11/21/2020 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />Pressure Test <br />Secondary Lines <br />Vacuum Test <br />Annular Tanks <br />Hydrostatic Test <br />UDCs and Sumps <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />1 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. 1 understand that test procedures shall be <br />made available upon request by the governing authority. <br />Service Technician Signature <br />�S <br />Date <br />10/16/2020 <br />Total # of Pages <br />5 <br />6. TANK SECONDARY CONTAI MENT 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 />