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Appendix'Al 21200262 <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION Installation Repair [:]6 Month Z36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181087 <br /> 3/illza2l <br /> Facility Name <br /> Arco 2093 <br /> Facility Address City ZIP Code <br /> 3425 Tracy Blvd. Tracy 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test <br /> f3hone <br /> ettler-Ryan Inc.Iac. <br /> 925-551-7444 <br /> Mailing Address <br /> 6805 Sierra Court, Suite 0, Dublin, CA 94568 <br /> Service Technician Performing Test <br /> Terrell Taylor <br /> Contractor/Tank Tester License Number <br /> 220793 <br /> ICC Number ICC Expiration Date <br /> 93157661:812C <br /> g 2 2Q21 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder root Tech Cert #C27879 7/30/2022 <br /> Incon Level 4 Tech Cert #1017713712 12/21/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic All Sumps & UCD's <br /> Vacuum All Annular Tanks <br /> Pressure All Piping <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. /understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total# of Pages <br /> 3/11/2021 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 />