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Appendix VI#f <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE SOF ACTION L7 Installation Repair L7 12 Month <br /> CERS ID -- ? Test Date <br /> 9-23-2021 <br /> Facility Name ---- - -_ --___— <br /> �Gas and Shop Truck Stop ( Gemco Truck Plaza= ._ <br /> Facility Address City -- ZIP Cade <br /> 1002 E. Frontage Road ` Ripon CA 05366 <br /> - -- <br /> IAN tNIFC3R AT 3N f <br /> Company Performing the Test Phone <br /> I Self Serve Pe..frolpitm :650 588-3088 <br /> Mailing Address <br /> 1045 Airport Blvd. South San Francisco CA 94080. _--- <br /> Service Technician Performing Test <br /> Robert Neime er <br /> Contractor/Tank Tester License Number <br /> Gen A / Haz 930666 { <br /> [ ICC Number - --- --- — ICC Expiration Date I <br /> j 5248067 10-11-2021 I <br /> { <br /> !ice ASC?I ERTtF CATIt3NS <br /> I Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW 3-26-2023 <br /> 14I <br /> F `ICO3 <br /> Test Procedures Used Components Tested — <br /> PEI regular fill bucket, super fill bucket <br /> i <br /> ,4L q <br /> E <br /> i <br /> '1 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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature I Date Total # of Pages <br /> AA� �� 9-23-2021 7 <br /> Ll <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />