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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 />10181399 <br />Test Date <br />11/05/2021 <br />Facility Name <br />Grant Line Shell <br />Facility Address <br />2375 W. Grant Line <br />City <br />Tracy <br />ZIP Code <br />95376 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Able Maintenance, Inc. <br />Phone <br />(707) 545-5522 <br />Mailing Address <br />3224 Regional Parkway, Santa Rosa CA 95403 <br />Service Technician Performing Test <br />John Rodriguez <br />Contractor/Tank Tester License Number <br />Able Maintenance, Inc. / 312844 <br />ICC Number <br />8950078 <br />ICC Expiration Date <br />10/14/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />FFS EBW/Phil-Tite EVR Phase 1 - UST # 1000943712 <br />03/05/2022 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PEI 1200 <br />87-1 & 87-2 & DSL 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 ? p <br />Date <br />11/05/2021 <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 />