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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair 0 12 Month <br />1. FACILITY INFORMATION <br />CERS ID 10182137 Test Date 03/31/25 <br />Facility Name G EORG ES MINI MART <br />Facility Address 18662 HWY 88 City LOCKEFORD ZIP Code <br />95237 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the TestNORCALTANK TESTING Phone <br />209-712-6366 <br />Mailing Address 877 BATEMAN WAY GALT CA 95632 <br />Service Technician Performing Test David Winkler <br />Contractor/Tank Tester License Number 08-1739 02/28/26 <br />ICC Number 8883059 -UT <br />ICC Expiration Date <br />1/30/26 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW #104-633 <br />03/10/26 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />LAKE TEST <br />ALL OPW FILL BUCKETS <br />_7 <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 Sianature Date 03/31/25 <br />I w <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />