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Appendix VIII Permit #SR0083831 <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 /> 10166883 6/24/2021 <br /> Facility Name <br /> Super Stores Industries <br /> Facility Address City ZIP Code <br /> 16888 McKinley Avenue Lathrop 95330 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Elite IV Contractors (209) 461-6337 <br /> Mailing Address <br /> 2535 Wigwam Drive Stockton, CA 95205 <br /> Service Technician Performing Test <br /> Joseph Bartholdi <br /> Contractor/Tank Tester License Number <br /> 1001331 A-Hazmat <br /> ICC Number ICC Expiration Date <br /> 8852851 4/13/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC UST Installation Retrofitting/Service Technician 4/13/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic Diesel Direct Bury <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 2637.9; 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 /> 6/24/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />