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Appendix Vii <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation 0 Repair ❑ 6 Month ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10184829 11/24/2022 <br /> Facility Name <br /> Food 4 Less <br /> Facility Address City ZIP Code <br /> 1427 S.Airport Way Stockton 98205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Able Maintenance,Inc. (707)545-5522 <br /> Mailing Address <br /> 3224 Regional Parkway,Santa Rosa CA 95403 <br /> Service Technician Performing Test <br /> John Rodriguez <br /> Contractor/Tank Tester License Number <br /> Able Maintenance,Inc.1312844 <br /> =8950078 <br /> IGC Expiration Date <br /> 10/03/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> INCON T5-STS L4#1000943712 03/22/2024 <br /> Icon Installer 47/24/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic UDC•s <br /> Pressure Secondary piping <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. l understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date TTotal #of Pages <br /> 11/24/2022 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 />