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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 <br />10181267 <br />Facility Name <br />Stockton AASF <br />Facility Address <br />2000 Stimson RD <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Tank Team, inc <br />Test Date <br />12/2/2021 <br />City ZIP Code <br />Stockton 95206 <br />Phone <br />(805) 432-0216 <br />Mailing Address <br />2745 Sherwin Ave, Ste. 3, Ventura, CA 93003 <br />Service Technician Performing Test <br />Bernard Olson <br />Contractor/Tank Tester License Number <br />512835 Eng A, C-10- C-57 HAZ <br />ICC Number <br />5252993 UT <br />ICC Expiration Date <br />8/17/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Incon STS, 10000103709 <br />12/22/2021 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PEI RP 1200 Section 6.2 <br />AST to Bulk Reel UDC <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 <br />Date <br />12/11/2021 <br />Total # of Pages <br />, </ <br />CERS = California Environmental Reporting System, ICC = International Code Council, <br />ID = Identification, NA = Not Applicable, UDC = Under -Dispenser Containment, <br />UN -054 www.unidocs.org Rev. 10/01/20 Page 1 of 5 <br />