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Appendix Vlll <br />Underg round Storage Tan k <br />Spill Container Testing Report Form <br />TYPE OF ACTION I lnstallation n Repair 8 12 Month <br />CERS ID <br />*crlity-Narfie <br />CALIFORNIA STOP <br />Facility Address <br />2224 S MANTHEY ROAD <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />MB SERVICES <br />Mailing Address <br />PO <br />Service Technician Performing Test <br />BR|AN pUNAHAY_ <br />Contractor/Tank Tester License Number <br />945643 <br />ICC Number <br />8021436 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />1. FACILIW INFORMAT|oN <br />Test Date <br />03r17t2021 <br />ICC Expiration Date <br />02t15t2023 <br />Jl:g'_1_ <br />I <br />oPW 0177221t---- <br />tr 11st pnoc- <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:!gtt"2! !rtS:!!!:" "h"il b" ^"d" """i <br />i Servrce Tectrnrcran Srgnatu'€ <br />ar----rF <br />i <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, lD = ldentification, ICC = International Code <br />Council <br />03t03t2023 <br />Page 1 of 2