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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 Test Date <br />10181399 05/26/2021 <br />Facility Name <br />GRANTLINE SHELL <br />Facility Address City ZIP Code <br />2375 W GRANT LINE TRACY 95376 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Service Station Systems, Inc. <br />Phone <br />(408) 971-2445 <br />Mailing Address <br />680 Quinn Ave, San Jose CA 95112 <br />Service Technician Performing Test <br />Samantha McMahan <br />Contractor/Tank Tester License Number <br />485184 <br />ICC Number <br />8950093 <br />ICC Expiration Date <br />09/18/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling # 1029453710 <br />10/26/2021 <br />O P W# 0182767 <br />01/22/2022 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PE11200 <br />SPILL BUCKETS <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 />Date <br />05/26/2021 <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 />