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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair M 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> Facility Name 03/23/2022 <br /> CALIFORNIA STOP <br /> Facility Address City ZIP Code <br /> 2224 S MANTHEY ROAD :::ISTOCKTON, CA 195206 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> MB SERVICES 707-439-3778 <br /> Mailing Address <br /> PO BOX 1299 SUISUN CITY CA 94585 <br /> Service Technician Performing Test <br /> BRIAN DUNAHAY <br /> Contractor/Tank Tester License Number <br /> 945643 <br /> ICC Number ICC Expiration Date <br /> 8021436 02/15/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VR B42286 03/08/2023 <br /> OPW 0177221 03/03/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> HYDROSTATIC SPILL CONTAINMENT <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> l 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. l understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date :2: <br /> al # of Pages <br /> C33uz� a 03/23/2022 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />