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CGRS Appendix Vll <br /> Underground Storage TankCompliance <br /> EED <br /> Seconda Containment Testing Report Form <br /> Secondary 9 p <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month ® 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10182249 01-21-2021 <br /> Facility Name <br /> Valley Pacific Petroleum Fresno Ave. <br /> Facility Address City ZIP Code <br /> 1524 Fresno Ave. Stockton 95206 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> CGRS Inc. 916 991-1100 <br /> Mailing Address <br /> 5444 Dry Creek Road; Sacramento CA. 95838 <br /> Service Technician Performing Test <br /> Garrett Warren <br /> Contractor/Tank Tester License Number <br /> CSLB#803616 <br /> ICC Number ICC Expiration Date <br /> 8185019 09/20/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> F.F.S. Incon Level 4 TS-STS Sump Testing Cert. #1000553709 01/07/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> RP-1200 / Cal CUPA Form Tank Annulars, Product Line Secondaries, UDCs & Tank Top 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 /> Garrett Warren �I � 01-21-2021 7 <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 />