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Appendix VIf <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month ® 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181191 12/15/2023 <br /> Facility Name <br /> Tulare Farms LLLP <br /> Facility Address City ZIP Code <br /> 2771 E French Camp Road Manteca 95336 <br /> �2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test 7T. 707 <br /> hone <br /> Duncan Compliance: Dba R&D Compliance Testing 621-0378 <br /> Mailing Address <br /> P.O. Box 1503 Ukiah Ca. 95482 <br /> Service Technician Performing Test <br /> Ben'amin Duncan <br /> Contractor/Tank Tester License Number <br /> Contractors License#1036490_ .. _ <br /> ICC Number ICC Expiration Date <br /> 5246802-UT 214125 _ <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Caldwell Systems Level Change Indicator 311126 <br /> PEI/RP 1200 Certificate of Completion-PEI Service Tech 5!4124-514124 <br /> Fiberglass SystemslNOV1CSl-FFS Pro Compliance Testing 4123124-5!25/25 <br /> Modern Welding Company-Western Fiberglass, Inc. 514!24-512125 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Vacuum Tank Secondary Containment <br /> Hydrostatic UDC's <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. 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 /> 12/15/2023 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 />