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Appendix VIII 21202049 <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />Dinstaiiation Repair 17112 Month <br />1.FACILITY INFORMATION <br />CERS ID Test Date <br />10181235 I 7/6/2021 <br />Facility Name <br />Arco 5450 <br />Facility Address I City ZIP Code <br />1617 W.Fremont Blvd.Stockton 95203 <br />2.SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test Phone <br />Gettler-Ryan Inc.925—551-7444 <br />Mailing Address 6805 Sierra Court,Suite C,Dublin,CA 94568 <br />Service Technician Performing Test <br />Darnell Smith <br />Contractor/Tank Tester License Number <br />220793 <br />ICC Number ICC Expiration Date <br />8709494 1112312021 <br />3.TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />OPW UST Tech Cert #0174705 7/6/2022 <br />5.CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />4.TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />1 Hour Hydrostatic <br />Components Tested <br />All Spill Buckets <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 />7/6/2021 2 <br />TYPE OF ACTION <br />CERS =California Environmental Reporting System,ID =Identification,ICC =International Code <br />Council <br />Page 1 of 2