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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 /> 1 FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10166191 02/10/2021 <br /> Facilit�r Name <br /> 7 ELEVE 35355 <br /> Facilitx Address Cly ZIP Code <br /> 3202 W H MMER LANE(N-136) STN KTON 95209 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Tanknology,Inc. 800-964-1250 <br /> Mailing Address <br /> 11000 N pac Expy#500 Austin,TX 78759 <br /> Service Technician Performing Test <br /> Jesus Saldivar <br /> Contractor/Tank Tester License Number <br /> 743160 <br /> ICG Number IGC Expiration Date <br /> 8361393 06/13/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW:EVR Phase 1 11/23/2022 <br /> ICC:CA UST Service Technician 06/13/2021 <br /> d. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> H2O TEST SPILL BUCKET <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 Date Total# of Pages <br /> A. 2-10-21 2 <br /> GERS = California Environmental Reporting System, ID = Identification, ICG = International Code <br /> Council <br /> Page 1 of 2 <br />