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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 /> 10181325 10/19/22 <br /> Facility Name <br /> Dart Container Store <br /> Facility Address City ZIP Code <br /> 1400 E. Victor Rd. Lodi, Ca 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Alltech Petro, Inc. 209-559-1616 <br /> Mailing Address <br /> P.O. Box 4208 Sonora Ca, 95370 <br /> Service Technician Performing Test <br /> Isaac Anderson <br /> Contractor/Tank Tester License Number <br /> Ca 623541/09-1749 <br /> ICC Number ICC Expiration Date <br /> 8146912 09/10/22 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Incon Secondary Containment Testing #1022863709 12/15/23 <br /> Caldwell Systems Sump Tester 04/01/23 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> RP-1200 / Manufacturer Diesel Tank Annular <br /> Caldwell Sump Tester <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 /> 10/19/22 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 />