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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION Ll Installation LJ Repair R1 12 Month <br /> 1. FACILITY INFORMATION <br /> CE RS ID Test Date <br /> 10165883 12/13/2022 <br /> Facility Name <br /> 7-ELEVEN#20632,MKT 2368 <br /> Facility Address City ZIP Code <br /> 4627 DA VINCI DR @ MARCH LN STOCKTON 95207 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Tanknology,Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N Mopac Expy#500 Austin,TX 78759 <br /> Service Technician Performing Test <br /> Jarrod Cooke <br /> Contractor/Tank Tester License Number <br /> 743160 <br /> ICG Number ICC Expiration Date <br /> 8155550 03/18/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC:CA UST Service Technician 03/18/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Lake Test Fill Spill Buckets <br /> §. 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 2637.7; that required supporring <br /> documentation is attached; and all information conrained herein is accurate. l understand <br /> rhar resr procedures shall be made available upon request by the governing aurhoriry. <br /> Se€vice Technician Signature Date Total # of Pages <br /> 12/13/2022 2 <br /> CERS = California Environmental Reporting System, ID = Identifcation; ICC = International Code <br /> Council <br /> Page 1 of 2 <br />