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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION Q Installation Repair U1 n Month 0 36 Month <br />1. FACILITY INFORMATION <br />CERS ID Test Date <br />11/08/2021 <br />Facility Name <br />Stockton 71 <br />Facility AddressCit�r <br />1990 Piccoli Road <br />Stock on <br />ZIP Code <br />95215 <br />2. SERVICE TECHNICIAN INFORMATION <br />Com am Performing the Test <br />Tanknol gy, In . <br />Phone <br />800-964-1250 <br />Mailing Address <br />11000 N pac Expy #500 Austin, TX 78759 <br />Service Technician Performing Test <br />Jarrod Cooke <br />ContractorlTank Tester License Number <br />743160 <br />ICC Number <br />8155550 <br />IGG Expiration Date <br />03/18/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />ICC:CA UST Service Technician 03/18/2023 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used Components Tested <br />lake test stp/udc <br />pressure test secondary lines <br />vacuum test annular <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that the secondary containment was rested in accordance with California <br />Code of Regulations, title 23, division 3, chapter 16, section 2837; that required supporting <br />documentation is attached; and all information contained herein is accurate. l understand <br />that test procedures shag be made available upon request by the governing authority. <br />Service Technician Signature <br />Date <br />11/08/2021 <br />Total # of Pages <br />3 <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 />