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Appendix Vill <br /> Underground Storage Tank <br /> Spill Container Testing Deport Form <br /> TYPE OF ACTION El installation F—. Repair p 12 Month <br /> 9. FACILITY INFORMATION <br /> CERS ID - - - - Test Date <br /> 40180554 - San Joaquin EMD 612512025 <br /> Facility flame <br /> C hevro n <br /> Facility Address City ZIP Code <br /> 444 Mossdale Rd Lathrop 195330 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> BZ Service Station Maintenance, Inc 1916-371-2380 <br /> Mailing Address <br /> 1044 Triangle Ct, W Sacramento, CA 95805 <br /> Service Technician Performing Test <br /> Steve Miller II <br /> ContfacterfTank Tester License Number <br /> 433159 _ <br /> ICC Number ICC Expiration Date <br /> 10323943 211 212026 <br /> . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW - 1193504 311412027 <br /> . TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI 1200-19 p94-17 3 spill buckets <br /> 6. CE RTI FICATI0N BY SEikt ICE 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 2837.1 that required suppoMng <br /> documentation 1s attached; and all information contained herein is accurate. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> erviTecrhnician Signature Date Total# of Pages <br /> 7� 1512512025 <br /> CER S = Califomia Environmental Reporting Systems, ID = Identification, i CC = International Code <br /> Council <br /> Page 1 of <br />