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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 />10187387 <br />Certification Date <br />11/15/2021 <br />Facility Name <br />Cruisers 76 <br />Facility Address <br />1137 W Lathrop Rd <br />City <br />Manteca <br />County <br />San Joaquin EMD <br />Zip Code <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification Phone <br />BZ Service Station Maintenance <br />916-371-2380 <br />Mailing Address <br />1041 Triangle Ct, West Sacramento, CA 95805 <br />Contractor/Tank Tester License Number <br />433159 <br />Service Technician Performing Test <br />Rhome Desbiens <br />ICC Number <br />8245558 <br />ICC Expiration Date <br />12/10/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer .& Test Equipment Training Certifications <br />Expiration Date <br />FFS Philtite - 1007293709 <br />3/12/2023 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Component(s) Tested <br />PEI 1200-17 section 6.2 <br />1 spill bucket <br />5. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br />1 hereby certify that each soil/ container was tested in accordance with California Code of <br />Regulations, title 23, division 3, chapter 16, section 2637.1,- that required supporting documentation <br />is attached; and all information contained herein is accurate. / understand that test procedures shall <br />be made available upon request by the governing authority. <br />Service Technician Signature <br />Date <br />11/15/2021 <br />Total # of Pages <br />CERS= California Environmental Reporting System. .'er Hour, ID= Identification, ICC= <br />International Code Council <br />