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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION 1=1 Installation 1=1 Repair El 6 Month Z 36 Month <br />I. FACILITY INFORMATION <br />CERS ID Test Date <br />10/11/2022 <br />Facility Name <br />SAFEWAY 2707 <br />Facility Address <br />6425 PACIFIC AVE <br />City <br />STOCKTON <br />ZIP Code <br />94577 <br />SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />ARMER/NORMAN & ASSOCIATES INC <br />Phone <br />925/671-9200 <br />Mailing Address <br />2600 WILLIAMS ST <br />Service Technician Performing Test <br />MAURICIO MIRANDA <br />Contractor/Tank Tester License Number <br />256896 <br />ICC Number <br />8407460 <br />ICC Expiration Date <br />12/2/2023 <br />TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />STS 1000623710 2/18/2023 <br />TEST PROCEDURE INFORMATION <br />Test Procedures Used Components Tested <br />PEI RP-1200 PRODUCT SECONDARY PIPING QTY (6) ZONES/RUNS <br />FFS STS ALL UDC, QTY (8) <br />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 />E/1/(ii2 011714- <br />Date <br />10/11/2022 <br />Total # of Pages <br />25 <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