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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month 0 36 Month <br />1 1. FACILITY INFORMATION <br />CERS ID Test Date <br />10156809 03/20/2023 <br />Facility Name <br />Safeway 1769 <br />Facility Address City ZIP Code <br />2802 Country Club Blvd. Stockton 95204 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Able Maintenance, Inc. <br />Phone <br />(707) 545-5522 <br />Mailing Address <br />3224 Regional Parkway, Santa Rosa, CA 95403 <br />Service Technician Performing Test <br />Michael McCarter <br />Contractor/Tank Tester License Number <br />Able Maintenance, Inc. / 312844 <br />ICC Number <br />8819839 <br />ICC Expiration Date <br />09/24/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />INCON TS -STS L4 - 1019623710 <br />09/20/2024 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />Hydrostatic <br />Sumps, UDC's <br />Pressure <br />Secondary piping <br />Vacuum <br />Tank Annulars <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. I understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />�5__- <br />Date <br />03/21 /2023 <br />Total # of Pages <br />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 />