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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION W Installation ❑ Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10180905 11/23/2021 <br /> Facility Name <br /> SYNERGY PETROLEUM ENTERPRIZES <br /> Facility Address City ZIP Code <br /> 6131 PACIFIC AVENUE STOCKTON 95207 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> TANK-TIGHT SYSTEMS, INC 916-667-6891 <br /> Mailing Address <br /> 8515 WATERMAN ROAD, ELK GROVE, CA 95624 <br /> Service Technician Performing Test <br /> BRIAN ROTH <br /> Contractor/Tank Tester License Number <br /> 1066914 <br /> ICC Number ICC Expiration Date <br /> 8834817 11/14/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC SERVICE TECHNICIAN 11/14/2023 <br /> VAPOR RECOVERY INSTALLATION AND REPAIR 11/27/2023 <br /> OPW EVR PHASE 1 10/21/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> HYDROSTATIC DSL AND 91 SPILL BUCKET <br /> WITH MEASURMENTS <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 /> 11/23/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />