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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month 0 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10156811 08/11/2022 <br /> Facility Name <br /> Safeway 2707 <br /> Facility Address City ZIP Code- <br /> 6425 <br /> ode6425 N. Pacific Ave. Stockton 95207 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Able Maintenance, Inc. (707) 545-5522 <br /> Mailing Address <br /> 3224 Regional Parkway, Santa Rosa CA 95403 <br /> Service Technician Performing Test <br /> Michael McCarter <br /> Contractor/Tank Tester License Number <br /> Able Maintenance, Inc./312844 <br /> ICC Number ICC Expiration Date <br /> 8819839 09/24/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> INCON TS-STS L4#1019623710 09/23/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic Sumps, UDC's <br /> Pressure Secondary piping <br /> Vacuum Tank annulars <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 f Date Total # of Pages <br /> 08/11/2022 6 <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 />