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Appendix V11 <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month 9 36 Month <br /> I. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10156057 07-13-2023 <br /> Facility Name — — - <br /> UPS <br /> Facility Address City ZIP Code <br /> '1532 North Broadway Stockton 95205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> ' Company performing the Test =P,10oe <br /> R.L Stevens Co 889.0908 <br /> Mailing Address <br /> P,O Box 361 San Leandro Ca. 94577 <br /> Service Technician Performing Test <br /> David Pereira _ <br /> ContractorlTank Tester License Number <br /> 415807 _ <br /> ICC Number ICC Expiration Date <br /> 5240739 0712712024 <br /> 3. TRA[NING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Dale <br /> INCON Sump Tester Level 4 03-13.2024 <br /> Fiberglass Systems 05.09-2025 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> pressure secondary pipe <br /> hydrostatic UDC &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 2537; that required supporting <br /> documentation is attached; and all information contained herein is accurate. 1 understand <br /> tha st pr edures shall be made available upon request by the governing authority. <br /> Se�v lan Signature Date Total #of Pages <br /> 07-13-2023 6 <br /> CERS = mental Reporting System, IGC = International Code Council, <br /> ID = Identification, NA = Not Applicable, UDC = Under-Dispenser Containment, <br /> Page 1 of 5 <br />