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Appendix Vill <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION Ij Installation E Repair 23 12 Morith <br /> I. FACILITY INFORMATION <br /> CERS ID Test Data <br /> 10911469 - San Joaquin EMD 1911012025 <br /> Facility Name <br /> rappa Market Shell <br /> Facility Address City ZIP Code <br /> 704 N Jacktone Rd Ripon 95366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing 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 /> Contractor/Tank Tester License Number <br /> 483189 <br /> ICD Number - — 11: Expiration Date <br /> 10323143 211212025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS Philtite - 6969423715 412412027 <br /> 4. TEST ARocEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> ILEI 1200-19 p14-17 4 spill buckets l� <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING 'FEST <br /> 1 hereby certify tha# each spl11 container was tested in accordance with Califomia Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637.1; that requfred supporting <br /> documentation is attached; and ail information contained herein is accurate. l understand <br /> that test procedures shall be made avaifabfe upon request by the governing authority. <br /> Service Technician Signature Date w Total #of Pages <br /> 911012025 <br /> DERS = California Environmental Reper#ng Systern, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />