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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑✓ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID 10181579 Test Date 1/28/2021 <br /> FacilityName BAGLEY - TRACY UNIFIED SCHOOL DISTRICT <br /> Facility Address City ZIP Code <br /> 1975 W. LOWELL AVENUE TRACY, CA 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the TestAFFORDATEST Phone <br /> 209-744-0112 <br /> Mailing Address 416 2ND STREET GALT, CA 95632 <br /> Service Technician Performing Test ZAN E N I M M O <br /> Contractor/Tank Tester License Number 04-1676 EX. 3/31 /22 <br /> ICC NumberICCICC Expiration Date <br /> 6/1/21 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling - EBW & Phil Tite #10009843708 Ex.11/30/2022 <br /> OPW #104-632 Ex. 3/15/2022 <br /> C N 1 # 4386 Ex. 1/20/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> LAKE TESTING SPILL BUCKET , DRAIN VALVE AND ADAPTER <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I 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 Sianature Date 1/28/21 Total # of Pages <br /> 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />