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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION ❑ Installation ® Repair ❑ 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10118074 <br />Certification Date <br />03/15/2023 <br />Facility Name <br />Circle K <br />Facility Address <br />2575 Country Club <br />CityCounty <br />Stockton <br />Zip Code <br />95204 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Elite IV Contractors <br />Phone <br />(249) 461-6337 <br />Mailing Address <br />2535 Wigwam Dr Stockton CA <br />Contractor[Tank Tester License <br />Number 1001331 <br />Service Technician Performing Test <br />Ben Malaspina <br />ICC Number <br />9519380 <br />ICC Expiration Date <br />06/17/2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer & Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling EVR Phase 1 1019683711 <br />08/23/2023 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Component(s) Tested <br />Hydrostatic <br />(1) Diesel Spill Bucket <br />5. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br />1 hereby cenDfy drat each spill container was tested in accordance with Califomia Code of <br />Regulafions, df►e 23, division 3, chapter 16, section 2637.1; that ►aquifed suppo4ng documentation <br />Is aitachei% and all information contained herein is accuratel understand that test proceduras shall <br />be made available upon request by the goveming authoMy. <br />Se .ice Technician Signature <br />Date <br />03/15/2023 <br />Total # of Pages <br />2 <br />C S= California Environmental Reporting System, GPH= Gallons Per Hour, ID= Identification, ICC= <br />International Code Council <br />