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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION O Installation _ Repair V 12 I'donth <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10165777 09/16/2021 <br /> FaciIE Name <br /> 7-ELEVE 14113,MKT 2368 <br /> Facility Address Cit ZIP Code <br /> 3040 BENJAMIN HOLT DR @ GRIGSBY STO ON 95219 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Tanknology,Inc. 800-964-1250 <br /> Mailin�q Address <br /> 11000 N opac Expy#500 Austin,TX 78759 <br /> Service Technician Performing Test <br /> Jesus Saldivar <br /> Contractorgank Tester License Number <br /> 743160 <br /> ICC Number ICC Expiration Date <br /> 8361393 06111/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW:EVR Phase 1 11/23/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> h20 test Spill bucket <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that each spill container was rested in accordance with California Code of <br /> Regulations, rifle 23, division 3, chapter 96, section 2637.9; that required supporting <br /> documentation is attached;and all information contained herein is accurate. l understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total# of Pages <br /> 09/16/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />