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Appendix 5 <br /> Underground Storage Tank <br /> Release Detection Equipment Testing Report Form <br /> TESTING TYPE ❑ Installation ❑ Repair 0 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10118074 01/20/26 <br /> Facility Name <br /> COUNTRY CLUB MOBIL <br /> Facility Address City ZIP Code <br /> 2575 COUNTRY CLUB BLVD STOCKTON 95204 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing Testing Phone <br /> Norcal Petroleum Tank Testing 209-737-8378 <br /> Mailing Address <br /> 877 Bateman Way Galt CA 95632 <br /> Service Technician Performing Testing <br /> David Winkler <br /> Contractor License Number <br /> 1115912 <br /> ICC Certification ICC Expiration Date <br /> 8883059-UT 01/30/2026 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Training Expiration Date <br /> Veeder Root B34975 01/28/26 <br /> Incon 1009853708 12/9/26 <br /> VMI 2529 11/11/27 <br /> Bravo 2024-2929502 1/19/27 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that all equipment identified in this form has been tested in accordance with <br /> California Code of Regulations, title 23, division 3, chapter 16, section 2663; that required <br /> supporting documentation is attached; and all information contained herein is accurate. <br /> Service Technician Signature �.� �,�� Date Total # of Pages <br /> 01/20/26 6 <br /> CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, UDC = Under- <br /> Dispenser Containment, UST = Underground Storage Tank, VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />