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Appendix VII <br /> Underground Storage Tank SR0082635 <br /> Secondary on ainment Testing Report Form <br /> TYPE OF ACTION El Installation M Repair rl 6 Month El 36 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Test Date <br /> 1 /25/2021 <br /> Facility Name <br /> Lathrop Shell <br /> Facility Address City ZIP Code <br /> 16500 S Harlan Rd Lathroop 95330 <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 />( 2524811 6/19/2021 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC Service Technician 5254811 6/19/2021 <br /> Bravo Frames 2019-2929473 4/02/2022 <br /> 4 . TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Pressure Test 87 Secondary <br /> Hydrostatic 5 / 6 UDC <br /> 5 . CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 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. l understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician ignature Date Total # of Pages <br /> 2/25/2021 <br /> CERS = California Environmental Reporting System , ICC = International Code Council , <br /> ID = Identification , NA = Not Applicable , UDC = Under- Dispenser Containment , page 1 of 5 <br />