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Appendix VIII 212041455 <br /> Underground Storage Tank Gas Side <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION F711nstallation ā¯‘Repair Z12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10894996 8/22/2022 <br /> Facility Name <br /> Arco 7092 <br /> Facility Address City ZIP Code <br /> 2510 S. Hwy 99 Stockton 95205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Gettler-Ryan Inc. 925-551-7444 <br /> Mailing Address <br /> 6805 Sierra Court, Suite G, Dublin, CA 94568 <br /> Service Technician Performing Test <br /> Robert Jacobs <br /> Contractor/Tank Tester License Number <br /> 220793 <br /> ICC Number ICC Expiration Date <br /> 8819943 6/17/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW UST EVR Phase 1 Tech Cert #0177621 3/30/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> 1 Hour Hydrostatic All Spill Buckets <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 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 /> 8/22/2022 2 <br /> CERS = California Environmental Reporting System, ID_ = Identification_, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />