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Appendix VIII 01 <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair p 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181455 11/19/2020 <br /> Facility Name <br /> Unified Grocers, Inc. <br /> Facility Address City ZIP Code <br /> 1990 Piccoli Rd. Stockton 95215 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> TAIT Environmental Services, Inc. (714) 560-8222 <br /> Mailing Address <br /> 11280 Trade Center Dr., Rancho Cordova, CA 95742 <br /> Service Technician Performing Test <br /> Jaime Jauregui <br /> Contractor/Tank Tester License Number <br /> 588098 <br /> ICC Number ICC Expiration Date <br /> 8340695 08-08-2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW 103918 01-22-2022 <br /> STS- 1012613712 04-13-2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Incon/hydrostatic Spill Container <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that each spill container was tested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637.1; 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 Date Total # of Pages <br /> 11/19/2020 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />