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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 /> 10181399 11/05/2021 <br /> Facility Name <br /> Grant Line Shell <br /> Facility Address City ZIP Code <br /> 2375 W. Grant Line Tracy 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Able Maintenance, Inc. (707)545-5522 <br /> Mailing Address <br /> 3224 Regional Parkway,Santa Rosa CA 95403 <br /> Service Technician Performing Test <br /> John Rodriguez <br /> Contractor/Tank Tester License Number <br /> Able Maintenance, Inc./312844 <br /> ICC Number ICC Expiration Date <br /> 8950078 10/14/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS EBW/Phil-Tite EVR Phase 1 -UST#1000943712 03/05/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI 1200 87-1 &87-2&DSL SPILL BUCKETS <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 /> 11/05/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />