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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑x Repair ❑ 6 Month ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181387 5/27/2022 <br /> Facility Name <br /> Ryder Truck - Stockton <br /> Facility Address City ZIP Code <br /> 3633 Duck Creek Dr. Stockton 95215 <br /> 2, SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Balch Petroleum (408) 942-8686 <br /> Mailing Address <br /> 930 Ames Ave. Milpitas, CA 95035 <br /> Service Technician Performing Test <br /> Rolando Urbina <br /> Contractor/Tank Tester License Number <br /> 936575 <br /> ICC Number ICC Expiration Date <br /> 8009631-UT 8/19/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Caldwell Systems 10/1/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> RP1200 Secondary Lines, Piping Sump <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Signature Date Total # of Pages <br /> 5/27/2022 5 <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 />