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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 /> 10156811 01/05/2022 <br /> Facility Name <br /> Safeway 2707 <br /> Facility Address City ZIP Code <br /> 6425 N Pacific Ave. Stockton 95207 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Service Station Systems, Inc. (408) 971-2445 <br /> Mailing Address <br /> 680 Quinn Ave, San Jose CA 95112 <br /> Service Technician Performing Test <br /> Randy Wilkerson <br /> Contractor/Tank Tester License Number <br /> 485184 <br /> ICC Number ICC Expiration Date <br /> 8822029 12/10/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling#1001093708 01/12/2022 <br /> OPW#100593 12/10/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> 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. 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 /> 01/05/2022 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />