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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 <br />10403278 <br />Test Date <br />2022-05-19 <br />Facility Name <br />Lodi CA FO Term (Intl) <br />Facility Address <br />2500 West Turner Road <br />City <br />Lodi <br />ZIP Code <br />95242 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />SunWest Engineerin-q Constructors Inc <br />Phone <br />888 588-8737 <br />Mailing Address <br />4780 Cheyenne Way, Chino CA 91710 <br />Service Technician Performing Test <br />Leonardo A uilar Jr. <br />Contractor/Tank Tester License Number <br />703190 <br />ICC Number <br />5302718 <br />ICC Expiration Date <br />12-02-2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />FFS Sump Test System Operation INCON Level 4 <br />10/25/2023 <br />Owen's Corning <br />2/6/2024 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <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. 1 understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />Date <br />2022-05-19 <br />Total # of Pages <br />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 />