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Appendix VIII 20209729 <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 Test Date <br /> 10182191 <br /> 12/31/2020 <br /> Facility Name <br /> Arco 2186 <br /> Facility Address City ZIP Code <br /> 3212 N California. Stocktvrn 95204 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Gettler-Ryan Inc. 925-551-7555 <br /> Mailing Address <br /> 6805 Sierra Court, Suite G., Dublin, CA 99568 <br /> Service Technician Performing Test <br /> Terrell Taylor <br /> Contractor/Tank Tester License Number <br /> 220793 <br /> ICC Number ICC Expiration Date <br /> 9315756 8/23/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW Tech Cert #0189830 3/31/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> 1 Hour Hydrostatic Spill Buckets <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. l understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature DateTotal# of Pages <br /> f 12/31/2020 <br /> CERS = California Environmental R /Porting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />