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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION 17 Installation EZ Repair 17 6 Month El 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 3/16/2021 <br /> Facility Name <br /> Grupe Commercial Hanger 2 Gate 16 <br /> Facility Address City ZIP Code <br /> 5000 S Lindbergh Street Gate 16 Stockton 95206 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Elite IV Contractors 209 461-6337 <br /> Mailing Address <br /> 2535 Wigwam Drive Stockton, CA 95205 <br /> Service Technician Performing Test <br /> Michal Kennard <br /> Contractor/Tank Tester License Number <br /> 1001331 <br /> ICC Number ICC Expiration Date <br /> 4811 6/19/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC UST Service Technician 6/19/2021 <br /> 4, TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic Caldwell Turbine STP Sump <br /> S. 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 96, 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 Signatur Date Total # of Pages <br /> <� 3/16/2021 <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 />