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Appendix VIII kc?,ii C(23 <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ® Installation © Repair p 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10863526 9-22-2023 <br /> Facility Name <br /> 7-Eleven #41187 <br /> Facility Address City ZIP Code <br /> 1829 N. Wilson Way Stockton 95205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Walton Engineering, Inc. 916-373-1166 <br /> Mailing Address <br /> P.O. Box 1025, West Sacramento, CA 95691 <br /> Service Technician Performing Test <br /> Nicholas Janoe <br /> Contractor/Tank Tester License Number <br /> 617238 <br /> ICC Number ICC Expiration Date <br /> 8712764 1/28/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW Phase 1 EVR 2-21-2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic Fill spill containers <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 /> 9-22-2023 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />