Laserfiche WebLink
Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION ❑ Installation ❑x Repair ❑ 6 Month Ir 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />1012484 <br />Test Date <br />8/18/2021 <br />Facility Name <br />Flyers #427 <br />Facility Address <br />3300 Waterloo Road <br />City <br />Stockton <br />ZIP Code <br />95205 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Walton Engineering, Inc. <br />Phone <br />(916) 373-1166 <br />Mailing Address <br />P.O. Box 1025, West Sacramento, CA 95691 <br />Service Technician Performing Test <br />David Delgado <br />Contractor/Tank Tester License Number <br />617238 <br />ICC Number <br />5246959 <br />ICC Expiration Date <br />9/18/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Bravo <br />12/11/2021 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />Hydrostatic <br />U DC's <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 />Z�)a.w-c � <br />Date <br />8/18/2021 <br />Total # of Pages <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 />