Appendix VII Underground Storage Tank
Secondary Containment Testing Report Form TYPE OF ACTION
☐ Installation
☐ Repair
☐ 6 Month
☐ 36 Month
1. FACILITY INFORMATION CERS ID
Test Date
Facility Name Facility Address
City
ZIP Code
2. SERVICE TECHNICIAN INFORMATION Company Performing the Test
Phone
Mailing Address Service Technician Performing Test Contractor/Tank Tester License Number ICC Number
ICC Expiration Date
3. TRAINING AND CERTIFICATIONS Manufacturer and Test Equipment Training Certifications
Expiration Date
4. TEST PROCEDURE INFORMATION Test Procedures Used
Components Tested
5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST I hereby certify that the secondary containment was tested in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2637; that required supporting documentation is attached; and all information contained herein is accurate. I understand that test procedures shall be made available upon request by the governing authority. Service Technician Signature Date Total # of Pages 6. TANK SECONDARY CONTAINMENT TEST CERS = California Environmental Reporting System, ICC = International Code Council, ID = Identification, NA = Not Applicable, UDC = Under-Dispenser Containment,
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