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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ® Installation ® Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 4/30/2021 <br /> Facility Name <br /> My Mini Mart <br /> Facility Address City ZIP Cotte <br /> 1756 N Wilson Way Stockton 95205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Elite IV Contractors (209) 461-6337 <br /> Mailing Address <br /> 2535 Wigwam Drive Stockton, CA 95205 <br /> Service Technician Performing Test <br /> Michal Kennard <br /> ContractorlTank Tester License Number <br /> 1001331 <br /> ICC Number ICC Expiration Date <br /> 4811 6/19/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> ICC Service Technician #5254811 6/19/2021 <br /> OPW EVR UST #104790 5/23/2021 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic 91 Spill Container <br /> 5. CERTIFICATION BY SERVICE 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 2637.9; 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 /> Service Technician Signature Date Total # of Pages <br /> > 4/30/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />