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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 <br />10181913 <br />Test Date <br />02/22/2021 <br />Facility Name <br />Shell <br />Facility Address <br />16500 S. Harlan Road <br />City <br />Lathrop, CA <br />ZIP Code <br />95330 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />ECO-CHEK Compliance, Inc. <br />Phone <br />888-500-2435 <br />Mailing Address <br />PO Box 1394 Lafayette CA 94549 <br />Service Technician Performing Test <br />Marco Ale'os <br />Contractor/Tank Tester License Number <br />958763 A <br />ICC Number <br />8415074 <br />ICC Expiration Date <br />04/27/2021 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW Phase 1 EVR #0177295 <br />03/04/2021 <br />FFS 1013893711 <br />07/25/2021 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PEI/RP1200 <br />Spill Bucket <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 Signature <br />, 1 <br />Date <br />02/22/2021 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />