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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION Ll Installation L� Repair 61 12 Month <br />!. FACILITY INFORMATION <br />GERS ID <br />10165883 <br />Test Date <br />12/23/2020 <br />1=acllltV NarTle <br />7 -ELEVEN #20632, MKT 2368 <br />Facilityy Address <br />4627 DA VINA DR @ MARCH LN <br />Glyy <br />STOCKTON <br />ZIP Code <br />95207 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Tanknology,Inc. <br />Phone <br />800-964-1250 <br />Mailing Address <br />11000 N pac Expy #500 Austin, TX 78759 <br />Service Technician Performing Test <br />Tim Elebeck <br />GontractorlTank Tester License Number <br />743160 <br />ICG Number <br />8001435 <br />IGG Expiration Date <br />06/17/2021 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW.,EVR Phase 1 <br />01/01/2022 <br />d. TEST PROCEDURE INFORMATION <br />Test Procedures Used Components Tested <br />lake test spill buckets <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. l understand <br />that rest procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />U'J"k <br />Date <br />12/23/20 <br />Total # of Pages <br />GERS = California Environmental Reporting System, ID = Identification, IGG = International Gode <br />Council <br />Page 1 of 2 <br />