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Appendix VIII 21202735 <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION Finstallation ❑Repair ❑✓ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10384776 8/1.6/2021 <br /> Facility Name <br /> Arco 2093 <br /> Facility Address City ZIP Code <br /> 3425 Tracy Blvd. Tracy 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Gettler-Ryan Inc. 925-551-7444 <br /> Mailing Address <br /> 6805 Sierra Court, Suite G, Dublin, GA 94568 <br /> Service Technician Performing Test <br /> Terrell Taylor <br /> Contractor/Tank Tester License Number <br /> 220793 <br /> ICC Number ICC Expiration Date <br /> 9315756 2/2812023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW EVR UST Tech Gert #0189380 3/31/2022 <br /> FPS RVR Phase 1 Systems VR-101 tech Cert #1017713712 1/7/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> 1 Hour Hydrostatic All spill Buckets <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. I understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 8/16/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />