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Appendix V11 Permit # SR0083895 / Two Guys / 7/23/2021 <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 Test Date <br /> 10181421 7/23/2021 <br /> Facility Name <br /> Two Guys Mobil #9718 <br /> Facility Address City ZIP Code <br /> 147 W Lathrop Rd Lathrop 95330 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Elite IV Contractors 209 461-6337 <br /> Mailing Address <br /> 2535 Wigwam Drive Stockton, CA 95205 <br /> Service Technician Performing Test <br /> Michal Kennard <br /> Contractor/Tank Tester License Number <br /> 1001331 A-Hazmat <br /> ICC Number ICC Expiration Date <br /> #4811 7106/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC Service Tech #4811 7/06/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Pressure Diesel Annular <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 96, 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 Si nature Date Total# of Pages <br /> z <br /> CERS = California Environmental Reporting System, ICC = International Code Council, <br /> ID = Identification, NA = Not Applicable, UDC = Under-Dispenser Containment, <br /> Pagel of 5 <br />