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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION E) Installation I] Repair u 6 tvlar•th R! 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10165823 11/07/2023 <br /> Facility Name <br /> 7-ELEVEN#17647, MKT 2368 (N-744) <br /> Facility Address City ZIP Code <br /> 1048 W.YOSEMITE AVE @ EL PORTEL MANTECA 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> FT <br /> ompany Performing the Test Phflne <br /> anknology,Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N Mopac Expy#500 Austin, TX 78759 <br /> Service Technician Performing Test <br /> Jarrod Cooke <br /> Contractor/Tank Tester License Number <br /> 743160 <br /> ICC Number ICC Expiration Date <br /> 8155550 03/08/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC:CA UST Service Technician 03/08/2025 <br /> PEI:RP1200 06/05/2079 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> lake test stp/udc sumps <br /> pressure test secondary lines <br /> vacuum test annular spaces <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 2 63 7; that required supporting <br /> documentarian 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 /> 11/07/2023 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 />