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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION Ll Installation LJ Repair 0 12 Month <br />1. FACILITY INFORMATION <br />CE RS ID Test Date <br />10165857 12/15/2022 <br />Facility Name <br />7 -ELEVEN #19976, MKT 2368 <br />Facllfty Address <br />1399 N. MAIN ST. @ NORTHGATE <br />City <br />MANTECA <br />ZIP Code. <br />95336 <br />2. SERVICE TECHNICIAN INFORIUTATION <br />Company Performing the Test <br />Tanknology, Inc. <br />Phone <br />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 />ICC Number ICC Expiration Date <br />8155550 03/18/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Dexfifications <br />Expiration Date <br />ICC:CA UST Service Technician <br />03/18/2023 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />lake test <br />Components Tested <br />sb <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that each spill container was rested in accordance with California Code of <br />Regulations, title 23, division 3, chapter 76, section 2637.7; that required supporting <br />documentation is attached; and all information contained herein is accurate. l understand <br />that rest procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />Date <br />12/15/2022 <br />Total # of Pagers <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = Internatlonal Code <br />Council <br />Page 1 of 2 <br />