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Appendix Vill <br /> Underground Storage Tank <br /> Spill ContainerTesting Report Form <br /> TYPE OF ACTION El Installation ® Repair EE 12 Month <br /> 1. FACILITY INFORMATION �1 <br /> CERS ID Test Date <br /> 10911469 - San Joaquin EMD 911912024 <br /> Facility Name <br /> Grappa Market - Shell <br /> Facility Address City ZIP Code <br /> 704 N Jack Tone Rd Ripon 195366 <br /> 2. SERVICE TECH NIIAN 1NFO RMATION <br /> Company Perfarming the Test Phone <br /> BZ Service Station Maintenance, Inc 916-371-2380 <br /> Mailing Address <br /> 1041 Triangle Ct, W Sacramento, CA 95805 <br /> Service Technician Performing Test <br /> Steven Miller II <br /> ontractorfTank Tester License plumber <br /> 1433159 <br /> ICC Number ICC Expiration Date <br /> 10323143 211212026 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS PHILTITE - 6969423715 6111/2025 <br /> 4. TEST PROCEDURE INFORMATION <br /> `est Procedures Used Components Tested <br /> PEI 1200.17 section 6.2 4 SPILL BUCKET <br /> I <br /> I <br /> 6. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST -- <br /> f hereby certify that each spill container was tested in accordance with California Code of <br /> Reguialions, title 23, division 3, chapter 16, section 2637.1; thaf required suppordn_q <br /> documentation is affach ed, and all information cnnfainad herain is accurate. f understand <br /> fhat test procedures shall be made available upon request by the governing authorrrty. <br /> Service Technician Signature Date Total # of Pages <br /> 911912024 <br /> CERS = Califomle Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />