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Ist irt*&en sRc815263 Amendwx) 81171N Wtjo3j3 <br /> 3 z 3 �YMata IA.Trac 'XA 45?9t <br /> Appendix VII <br /> Underground Storage Tank <br /> Containment Testing Report Form <br /> TYPE OF ACTION Installation ® Repair 17 6 Month ® 36 Month <br /> 1, FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181085 8/17/2021 <br /> Facility Name <br /> Country Mart Gas & Food <br /> Facility Address City ZIP Code <br /> 34243 S Crisman Road Tracy 95304 <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 /> Joseph Bartholdi <br /> Contractor/Tank Tester License Number <br /> 1001331 A-Hazmat <br /> ICC Number ICC Expiration Date <br /> 88852851 4/13/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Nov/Smith Fiberglass 0L <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Pressure Test Primary Piping 1st Inspection <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 T nici Signat re Date Total # of Pages <br /> 8/17/2021 2 <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 />