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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 10181065 Test Date 12/28/23 <br /> Facility Name NORTH POLE GAS <br /> Facility Address 574 GRANT LINE RD cityde <br /> TRACY 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Affords Test 209-744-0112 <br /> Mailing Address 416 2nd St Galt CA 95632 <br /> Service Technician Performing Test <br /> David Winkler <br /> Contractor/Tank Tester License Number 08-1739 Ex.3/31 /26 <br /> ICC Number ICC Expiration Date <br /> 8883059-UT 01/30/24 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling - EBW & Phil Tite # 240924345 11/28/24 <br /> OPW #104-633 03/10/24 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> LAKE TEST ALL FILL BUCKETS <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 Sianatuw <br /> re Date 12/28/23 Total # of Pages <br /> 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />