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Appendix VII <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 /> 10181249 02/07/2022 <br /> Facility Name <br /> ARP MINI MART MOBIL <br /> Facility Address City ZIP Code <br /> 25775 S Patterson Pass Rd Tracy 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Diamond Petroleum Services Inc. 1(925) 470-0803 <br /> Mailing Address <br /> 3619 King Ct Antioch CA 94509 <br /> Service Technician Performing Test <br /> Guadalupe Sanchez <br /> Contractor/Tank Tester License Number <br /> 1005444 <br /> ICC Number ICC Expiration Date <br /> 5250451 04/01/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Caldwell Systems Level Change Indicator 06/2022 <br /> Veeder Root Service ATG Service Tech 09/29/2023 <br /> ZCL/XERXES UST Installation 11/23/2022 <br /> Fiber Glass Systems / NOV 03/1/2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Pressure Test Secondary Lines <br /> Vacuum Test Annular Tanks <br /> Hydrostatic Test UDCs and Sumps <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 Date Total # of Pages <br /> 02/07/2022 5 <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 />