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Appendix VIII <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair <br />® 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Test Date <br />10146143 5/13/21 <br />Facility Name <br />Costco #1031 Manteca <br />Facility Address City ZIP Code <br />2440 Daniels St. Manteca 95337 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Alltech Petro Inc. <br />Phone <br />209-532-7320 <br />Mailing Address <br />P.O. Box 4208 Sonora Ca 95370 <br />Service Technician Performing Test <br />Chad White <br />Contractor/Tank Tester License Number <br />Ca 623541/09-1747 <br />ICC Number <br />8152115 <br />ICC Expiration Date <br />2/13/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />FFS EVR Phase 1 Systems <br />1015593710 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />Lake Test <br />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 <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 <br />Date <br />5/13/21 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />