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Appendix 11111 <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair M 12 Month <br /> I. FACILITY INFORMATION <br /> CERS 1D Test Date <br /> 10156057 05-24-2021 <br /> Facility Name <br /> UPS <br /> Facility Address City ZIP Code <br /> 1532 North Broadway Stockton 95205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> RL Stevens Co 510-8890908 <br /> Mailing Address <br /> P.O. Box 361 San Leandro CA 94577 <br /> Service Technician Performing Test <br /> David Pereira <br /> Contractor/Tank Tester License Number <br /> 415807 <br /> ]CC Number ICC Expiration Date <br /> 5240739 07128/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW UST 07/28/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic/PEI 1200 Spill bucket <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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Se i nature Date Total #of Pages <br /> 05-24-2021 2 <br /> CERS = California Environmental Reporting System, ID = identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />