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4 <br /> 10/26/21 Spill Container Testing Arco 18806 Lower Sacramento Rd Woodbridge CA 95258 <br /> Notification Required "Like for Like" <br /> 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 /> 10181237 10/261 021 <br /> Facility Name <br /> Arco <br /> Facility Address City ZIP Code <br /> 18806 Lower Sacramento Road Woodbridge 95258 <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 95203 <br /> Service Technician Performing Test <br /> Adrian Rodri uez <br /> Contractor/Tank Tester License Number <br /> 1001331 1 A-Hazmat <br /> ICC Number ICC Expiration Date <br /> 9914593 4/27/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW EVR VST #0192139 5/1912023 <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 /> 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 test procedures shall be ade available upon request by the governing authority. <br /> Service Technici fi Signatur Date Total # of Pages <br /> r 10/26/2021 2 <br /> (CERS = C Iifoa Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />