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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 Test Date <br /> 10154767 07-29-2021 <br /> Facility Name <br /> Lawrence Livermore National Laboratory Bldg. 882 <br /> Facility Address City ZIP Code <br /> 15999 W. Corral Hollow Road Tracy 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Thornton Environmental Construction, Inc. 209-832-0792 <br /> Mailing Address <br /> PO Box 360833 Milpitas, CA 95036-0833 <br /> Service Technician Performing Test <br /> Brian Thornton <br /> Contractor/Tank Tester License Number <br /> CSLB 724513 A, C-10, HAZ <br /> ICC Number ICC Expiration Date <br /> 5024962-UT 02-27-2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Caldwell Sump Level Change Indicator 05-11-2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI 1200 Spill Containment Bucket <br /> S. 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 Date Total#of Pages <br /> 07-29-2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />