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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 /> 5/ 14/21 <br /> Facility Name <br /> Fast & Easy Chevron <br /> Facility Address City ZIP Code <br /> 8660 N Lower Sacramento Rd Stockton , CA 95210 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> IEC Services 916 -993 -6312 <br /> Mailing Address <br /> 4901 Warehouse Way , Sacramento , CA 95826 <br /> Service Technician Performing Test <br /> Hayden Nunes <br /> Contractor/Tank Tester License Number <br /> 1064168 <br /> ICC Number ICC Expiration Date <br /> 9893815 1 /7/23 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW 1 /5/23 <br /> 4 . TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> 1 hour Lake Test 87 & 91 Fill Spill buckets . <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 16, section 2637. 1 ; that required supporting <br /> documentation is attached; and all information contained herein is accurate. / understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 5/ 14/21 2 <br /> CERS = California Environmental Reporting System , ID = Identification , ICC = International Code <br /> Council <br /> Page 1 of 2 <br />