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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION 0 Installation © Repair 0 6 Month 0 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 07/22/2025 <br /> Facility Name <br /> TRACY SHELL <br /> Facility Address City ZIP Code <br /> 3725 TRACY BLVD. TRACY 95304 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> JW'S FUEL SERVICES 559-991-6774 <br /> Mailing Address <br /> 2711 N. BOISE ST. VISALIA, CA. 93291 <br /> Service Technician Performing Test <br /> JACOB WEAVER <br /> Contractor/Tank Tester License Number <br /> 1069708 <br /> ICC Number ICC Expiration Date <br /> 8338858 01/08/2027 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> INCON # 1009763709 02/25/2027 <br /> NOV 07/11/2028 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> INCON SUMPS & UDC'S <br /> PRESSURE SECONDARY LINES <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 /> 07/22/2025 <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 />