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Appendix V111 <br /> Underground Storage Tangy <br /> Spill Container Testing porrt Form <br /> TYPE OF ACTION ® Installation ® Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10186837 9/8/2023 <br /> Facility Name <br /> Manteca Gas and Food C <br /> Facility Address 5�tt�ckton County Zip Code <br /> 1229 E. Louise Ave San Joaquin 95336 <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 /> Joe Bartholdi <br /> ICC Number ICC Expiration Date <br /> 8852851 917125 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer& Test Equipment Training Certifications Expiration Date <br /> FFS EVR Phase 1 Systems VR101 917125 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Component(s) Tested <br /> Hydrostatic 91 spill container <br /> 5. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br /> 1 hereby certify that each spill container was crested in accordance with Califomia Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637.1;that requirad supporting documentation <br /> is attached,-and all Information contained herein is accurate. /understand that test procedures shall <br /> be made a vallab*Mwn request by the go veming authodly. <br /> Service Tec . can gnature Date Total # of Pages <br /> 9/8/2023 2 <br /> CERS= Cp4fornia nvir€ amental Reporting System, GPH= Gallons Per Hour, ID= Identification, #CC= <br /> International Cade Council <br />