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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair Q 12 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10181479 2021 - 08 - 17 <br /> Facility Name <br /> Mid City CA FO Re en <br /> Facility Address City ZIP Code <br /> 13850 Devries Rd Lodi 95242 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> SunWest Engineering Constructors , Inc ( 888) 588 - 8737 <br /> Mailing Address <br /> 4780 Cheyenne Way , Chino CA 91710 <br /> Service Technician Performing Test <br /> Kraig Kinder <br /> Contractor/Tank Tester License Number <br /> 703190 <br /> ICC Number ICC Expiration Date <br /> 8296393 11 - 18 -2022 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Pneumercator Liquid Level Control and Leak Detection Systems 2023 - 02 - 16 <br /> FFS Spill Containment 2020 - 04 - 17 <br /> 4 . TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Industry Standard EBW 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. 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 /> 2021 - 08- 17 <br /> CERS = California Environmental Reporting System , ID = Identification , ICC = International Code <br /> Council <br /> Page 1 of 2 <br />