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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation 52 Repair ❑ 6 Month ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID 10182131 Test Date <br /> 4-21-2023 <br /> Facility Name Pilot 618 <br /> Facility Address City RiZIP Code <br /> 1501 Jack Tone Rd pon 95366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Jones Covey Group Inc 888-972-7581 <br /> Mailing Address 9595 Lucas Ranch Rd #100 Rancho Cucamonga Ca, 91730 <br /> Service Technician Performing Test <br /> Issac Garcia <br /> Contractor/Tank Tester License Number <br /> 804431 <br /> ICC Number 8192172 ICC Expiration Date <br /> 10/25/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> NOV Fiberglass Systems 6/21/2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> 5 psi for an hour PEI 1200 T1, T3, T5, T6 secondarys & secondary associated with 25-30 to include 26 sat <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 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 /> 4/21/2023 4 <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 />