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Appendix Vlll <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION I Installation n Reoair 8 12 Month <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />vR 842286 <br />oPW 0177221 <br />Test Procedures Used Components Tested <br />HYDROSTATIC SPILL CONTAINMENT <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that each spill container was fesfed 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 />i that test procedures shall be made available upon request by the governing authority. <br />1. FACILITY INFORMATION <br />CERS ID Test Date <br />03t17t2021 <br />Facility Name <br />CALIFORNIA STOP <br />Facility Address <br />2224 S MANTHEY ROAD <br />City <br />STOCKTON, CA <br />ZIP Code <br />95206 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />MB SERVICES <br />Phone <br />707-439-3778 <br />Mailing Address <br />PO BOX 1299 SUISUN CITY. CA 94585 <br />Service Technician Performing Test <br />BRIAN DUNATIAY <br />Conrracror,Tant< -r esrer LicenG Number <br />945643 <br />ICC Numbe <br />8021436 <br />ICC Expiration Date <br />02t15t2023 <br />Expiration Date <br />03t03t2023 <br />4. TEST PROCEDURE INFORMATION <br />Service Technician Signature Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, lD = ldentification, ICC = International Code <br />Council <br />Page 1 of 2