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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month ® 36 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10182335 2/ 10/2021 <br /> Facility Name <br /> CD & R Tracy Truck Stop Report 2 of 2 <br /> Facility Address City ZIP Code <br /> 3940 North Tracy Boulevard Tracy 95304 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> E <br /> Company Performing the Test Phone <br /> R& D Compliance Testing ' <br /> 707 621 -0378 <br /> Mailing Address <br /> P . O . Box 1503 Ukiah Ca . 95482 <br /> Service Technician Performing Test <br /> Beniamin Duncan <br /> Contractor/Tank Tester License Number <br /> Tank Tester License #90 - 1120 <br /> ICC Number ICG Expiration Date <br /> ( 5246802 =UT 3/20/2021 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications <br /> Expiration Date <br /> Caldwell Systems Level Change Indicator 6/10/2023 <br /> ICC Service Technician #5246802 -UT 3/20/2021 <br /> Underground Storage Tank Tester License #90 -1120 12/31 /2022 <br /> 4; . TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic UDC 's <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 /> 2/10/2021 5 <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 />