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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION D Installation LJ Repair 0 12 Month <br /> 1. FACILITY INFORMATION <br /> CE RS ID Test Date <br /> 10181229 01/03/2024 <br /> Facility Name <br /> 7-ELEVEN #43175/4873 <br /> Facility Address City ZIP Code <br /> 35 NORTH CHEROKEE LANE LODI 95240 <br /> . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Tanknology, Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N Mopac Expy#500 Austin,TX 78759 <br /> Service Technician Performing Test <br /> Jesus Saldivar <br /> Contractor/Tank Tester License Number <br /> 743160 <br /> ICC Number ICC Expiration Date <br /> 8361393 05/16/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW:EVR Phase 1 01/04/2025 <br /> . TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Vacuum test Spill buckets <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that each spill container was tested in accordance with California Code of <br /> Regularions, title 23, division 3. chapter 16, section 2637.7; that required supporting <br /> documentation is artached; and all information contained herein is accurate. I understand <br /> thar test procedures shall be made available upon request by rhe governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> /� IL- 01/03/2024 2 <br /> CERS = California Environmental Reporting System, ID = Identification. ICC = International Code <br /> Council <br /> Page 1 of 2 <br />