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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION © Installation © Repair FM 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />1012484 <br />Test Date <br />12-9-2021 <br />Facility Name <br />Flyers #427 <br />Facility Address <br />3300 Waterloo Road <br />City <br />Stockton <br />ZIP Code <br />95205 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Walton Engineering <br />Phone <br />(916) 372-1888 <br />Mailing Address <br />3900 Commerce Drive, West Sacramento, CA, 95691 <br />Service Technician Performing Test <br />Anthony Reyes <br />Contractor/Tank Tester License Number <br />617238 <br />ICC Number ICC Expiration Date <br />8293772 9-2-22 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW #103920 <br />5-25-23 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />Hydrostatic Test <br />Spill Containers <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 />Az <br />Date <br />12-9-2021 <br />Total # of Pages <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />