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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION © Installation © Repair Frvj 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Test Date <br />10180641 6/11/2025 <br />Facility Name <br />Quik Stop Market #148 <br />Facility Address City ZIP Code <br />205 W. Lockeford Street Lodi, CA 95240 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Walton Engineering, Inc. <br />Phone <br />916-373-1166 <br />Mailing Address <br />P.O. Box 1025, West Sacramento, CA 95691 <br />Service Technician Performing Test <br />Sean Davies <br />Contractor/Tank Tester License Number <br />617238 <br />ICC Number <br />10071552 <br />ICC Expiration Date <br />5/7/2026 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW Phase 1 EVR 1193954 <br />7/22/2026 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />Hydrostatic <br />Spill Containers <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 Signature Date Total # of Pages <br />1:y¢d'e, 6/11/2025 2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />