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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form SR0082635 <br />TYPE OF ACTION Installation El Repair 17 6 Month El 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />Test Date <br />1/25/2021 <br />Facility Name <br />Lathrop Shell <br />Facility Address <br />16500 S Harlan Rd <br />City ZIP Code <br />Lathroop 95330 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Elite IV Contractors <br />Phone <br />209 461-6337 <br />Mailing Address <br />2535 Wigwam Drive Stockton, CA 95205 <br />Service Technician Performing Test <br />Miehal Kennard <br />Contractor/Tank Tester License Number <br />1001331 <br />ICC Number ICC Expiration Date <br />2524811 6119/2021 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />ICC Service Technician 5254811 <br />6/19/2021 <br />Bravo Frames 2019-2929473 <br />4/02/2022 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used Components Tested <br />Pressure Test 87 Secondary <br />Hydrostatic 516 UDC <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />! 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. 1 understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />?' 1 <br />Date <br />2/25/2021 <br />Total # of Pages <br />f <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 />