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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION r Installation K Repair ❑ 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />Test Date <br />3/04/2021 <br />Facility Name <br />Billjar Valero <br />Facility Address <br />153 E 11th Street <br />City <br />Tracy <br />ZIP Code <br />95376 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Elite IV Contractors <br />Phone <br />(209) 461-6337 <br />Mailing Address <br />2535 Wigwam Drive Stockton, CA 95e6 <br />Service Technician Performing Test <br />Gilbert Garcia <br />Contractor/Tank Tester License Number <br />1001331 <br />ICC Number ICC Expiration Date <br />1864 6/2012021 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />ICC Service Technician #1864 <br />6/20/2021 <br />Franklin Fueling FFS EVR Phase I Systems VR 101 Installation #3708 <br />3/26/2021 <br />Franklin Fueling Spill Containment #3708 <br />1/12/2023 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />Hydrostatic <br />91 Fill Container <br />5. CERTIFICATION BY SERVICE <br />TECHNICIAN CONDUCTING TEST <br />1 hereby certify that each spill container was tested in accordance with California Code of <br />Regulations, title 23, division 3, chapter 96, section 2637.1; that required supporting <br />documentation is attached; and all information contained herein is accurate. l understand <br />that test procedures shall be made available upon request by the governing authority. <br />5ervicTechnician Signature <br />Date <br />3/04/2021 <br />Total # of Pages <br />Z <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />