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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION ❑Installation ❑Repair x12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10468777 <br />Test Date <br />10/20/2021 <br />Facility Name <br />Pacificwest Petroleum Inc. (ARCO am/pm # 83333) <br />Facility Address <br />65OW Valpico Rd <br />City <br />Tracy <br />ZIP Code <br />95376 <br />F2 --SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Diamond Petroleum Services, Inc. <br />Phone <br />(925) 470-0803 <br />Mailing Address <br />3619 King Ct Antioch, CA 94509 <br />Service Technician Performing Test <br />Guadalupe Sanchez <br />Contractor/Tank Tester License Number <br />1005444 <br />ICC Number <br />5250451 <br />ICC Expiration Date <br />04/01/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW Phase 1 UST EVR <br />06/05/2023 <br />FFS EVR Phase I VR -101 <br />03/04/2022 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />Hydrostatict Test <br />87,91 and Diesel Fill 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 documentation is <br />attached; and all information contained herein is accurate.) understand that test procedures shall be <br />made available upon request by the governing authority. <br />Service Technician Signature <br />Date <br />10/20/2021 <br />Total # of Pages <br />2 <br />6. SPILL CONTAINER DETAILS <br />Test Method Developed by ❑ Manufacturer x Industry Standard ❑ Professional Engineer <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />