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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION L) Installation J Repair 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181411 01/24/2024 1 <br /> Facility Name <br /> Rebel Store#0376 <br /> Facility Address i City ZIP Code <br /> 3725 Tracy Blvd iTracy 95304 <br /> 2. 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 /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> H20 LEAK 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 /> 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 /> 01/24/2024 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />