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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 /> 10181559 106/22/2021 <br /> Facility Name <br /> Kaiser Manteca <br /> Facility Address City ZIP Code <br /> 1777 W. Yosemite Avenue Manteca 95337 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Belshire Environmental Services (949) 460-5200 <br /> Mailing Address <br /> 25971 Towne Centre Drive, Foothill Ranch, CA 92610 <br /> Service Technician Performing Test <br /> David Walker <br /> Contractor/Tank Tester License Number <br /> 808313 <br /> ICC Number ICC Expiration Date <br /> 8854235 10/31/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> See Attached <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI - RP1200/Manufacturer 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 /> D& \-�A , 06/22/2021 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Pagel of 2 <br />