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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION © Installation <br /> EJ Repair ® 6 Month ® 36 Month <br /> 1. FACILITY INFORMATION Test Date <br /> CERS ID 4/28/2021 <br /> Facility Name <br /> My Mini Mart City ZIP Code I <br /> Facility Address Stockton 95205 <br /> 1756 N Wilson Way Stockton, CA 95205 <br /> 2. SERVICE TECHNICIAN INFORMATION I Phone <br /> Company Performing the Test 209) 461-6337 <br /> Elite IV Contractors <br /> Mailing Address <br /> 2535 Wi warnDrive Stockton, CA 95205 <br /> Service Technician Performing Test <br /> Contractor/Tank Tester License Number <br /> 1001331 ICC Expiration Date <br /> CC Number 6/19/2021 <br /> 48 <br /> rI11 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC Service Technician 611912021 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Gauge 87/91 Annular <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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 4/30/2021 <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 />