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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 />TYPE OF ACTION Installation Repair 6 Month 36 Month <br />CERS ID <br />10182247 <br />Test Date <br />7/28/2021 <br />Facility Name <br />Country Marketplace <br />Facility Address <br />1789 West Charter Way <br />City <br />Stockton <br />ZIP Code <br />95206 <br />Company Performing the Test <br />R&D Compliance Testing <br />Phone <br />707 621-0378 <br />Mailing Address <br />P.O. Box 1503, Ukiah, Ca. 95482 <br />Service Technician Performing Test <br />Benjamin F Duncan <br />Contractor/Tank Tester License Number <br />Tank Tester License #90-1120 <br />ICC Number <br />5246802-UT <br />ICC Expiration Date <br />2/17/2023 <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />Caldwell Systems/Level Change Indicator 6/10/2023 <br />PEI/RP 1200 Certificate of Completion 5/4/2024 <br />Fiberglass Systems/NOV/CSI 4/22/2024 <br />Western Fiberglass, Inc. 4/21/2023 <br />Test Procedures Used Components Tested <br />Vacuum Tank Secondary Containment <br />Pressure Product Piping Secondary Containment <br />Hydrostatic Piping Sumps/UDC's <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 Date <br />7/28/2021 <br />Total # of Pages <br />5 <br />1. FACILITY INFORMATION <br />2. SERVICE TECHNICIAN INFORMATION <br />3. TRAINING AND CERTIFICATIONS <br />4. TEST PROCEDURE INFORMATION <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST