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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation 0 Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10063345 11/17/2020 <br /> Facility Name <br /> Fast Lane Central Valley <br /> Facility Address City ZIP Code <br /> 116 Roth Road Lathrop 95330 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Confidence UST Services, Inc. (800) 339-9930 <br /> Mailing Address <br /> 16250 Meacham Road, Bakersfield, CA 93314 <br /> Service Technician Performing Test <br /> Ronald McEntee <br /> Contractor/Tank Tester License Number <br /> 804904 <br /> ICC Number ICC Expiration Date <br /> 9367289 09/16/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW(0176685) 12/13/2020 <br /> Veeder Root (C27930) 12/04/2021 <br /> Vmi 04/11/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Rp Pei 1200 Spill container <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 /> A6W^ 11/17/2020 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />