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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container 'Testing Report Fw <br /> TYPE OF ACTION ® Installation ❑ Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10 I S <br /> Facility Name <br /> Facility Address City County Zip Code <br /> 1111 E. kettlemen Ln Lodi an Joaquin 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Elite IV Contractors 209 461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr Stockton CA <br /> Contractor/Tank Tester License <br /> Number 1001331 <br /> Service Technician Performing Test <br /> Adrian Rodriguez <br /> ICC Number ICC Expiration Date <br /> 9914593 0811012025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer& Test Equipment Training Certifications Expiration Date <br /> OPW Phase 1 0192139 07/12/2025 <br /> Modern 03/09/2024 <br /> 4, TEST PROCEDURE INFORMATION <br /> Test Procedures Used Component(s) Tested <br /> Hydrostatic Diesel Spill Container <br /> Pressure Diesel Annular Space <br /> 5. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br /> I hereby cerafy Mat each spill container was tested in accordance with Califomia Code of <br /> Regulations, We 23, div%sion 3, chapter 16, section 2637.1;Mat required supporting documentation <br /> is anaahed and all information contained herein is accurate, l understand that test procedures shall <br /> be made available upon raquestby the goveming authority. <br /> Service Technician Signature Date Total # of Pages <br /> 10/05/2023 2 <br /> CERS= California Environmental Reporting System, CISH= Gallons Per Hour, ID= Identification, ICC= <br /> International Code Council <br />