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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION © Installation 0 Repair 0 6 Month I✓ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10180893 4-26-2021 <br /> Facility Name <br /> Quik Stop Market #132 <br /> Facility Address City ZIP Code <br /> 3555 W. Hammer Ln Stockton 95219 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Walton Engineering 916 373 1166 <br /> Mailing Address <br /> 3900 Commerce Drive, West Sacramento <br /> Service Technician Performing Test <br /> Anthony Reyes <br /> Contractor/Tank Tester License Number <br /> 617238 <br /> ICC Number ICC Expiration Date <br /> 8293772 8-2-2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Incon Lvl 4 3-2-2023 <br /> Xerxes 110212023 <br /> Fiberglass Systems 01/02/2023 <br /> Bravo 12/11/2021 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Vacuum Decay Tank annular <br /> Pressure Decay Secondary Product Line <br /> INCON STS Containment Sumps <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 Date Total # of Pages <br /> i� 4-26-2021 <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 />