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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 Test Date <br /> 10146151 05/16/23 <br /> Facility Name <br /> Costco #1091 Lodi <br /> Facility Address City ZIP Code <br /> 2680 Reynolds Ranch Parkway Lodi 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Alltech Petro, Inc 209-559-1616 <br /> Mailing Address <br /> P.O. Box 4208 Sonora Ca 95370 <br /> Service Technician Performing Test <br /> Isaac Anderson <br /> Contractor/Tank Tester License Number <br /> CA 623541/09-1749 <br /> ICC Number ICC Expiration Date <br /> 8146912 09/10/24 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW #100456 06/02/24 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI RP-1200/ 87A, 87B, 91 and Additive Spill Buckets <br /> Manufacturer <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I 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 /> ' 05/16/23 2 <br /> CERS = California Environmento4eporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />